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CONFIDENTIAL 2012N141241_00 The GlaxoSmithKline group of companies EGF114471

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Division: Worldwide Development Information Type: Clinical Study Report Control: [placebo]

Title: [EGF114471: Pharmacogenetic substudy for the determination of associations and predictive values of four MHC genetic variants for lapatinib-associated ALT elevation and hepatotoxicity using patients from EGF105485 (TEACH): A prospective validation of confirmed liver safety biomarkers HLA-DQA1*02:01 and DRB1*07:01.]

Phase: [III]

Compound Number: GW572016

Effective Date: 18-JUL-2012

Description:

This document describes results of a pharmacogenetic substudy to prospectively validate previously identified and confirmed genetic associations of four MHC variants with lapatinib-associated ALT elevation and serious liver injury. The substudy was conducted using clinical safety data and DNA collected from subjects who participated in EGF105485 (TEACH, A Randomised, Double-blind, Multicenter, Placebo-controlled Study of Adjuvant Lapatinib in Women with Early Stage ErbB2 Overexpressing Breast Cancer) and analysed retrospectively according to a prospectively defined Reporting and Analysis Plan. The results validate the association of HLA-DQA1*02:01 and -DRB1*07:01 allele carriage with ALT elevation and risk of serious liver injury that occurs during lapatinib treatment.

Subject: [lapatinib, adjuvant breast cancer, TEACH, EGF105485, EGF114471, PGx320, hepatobiliary disorders, ALT elevation, pharmacogenetics, MHC, HLA-DRB1*07:01, HLA-DQA1*02:01, prospective biomarker validation]

Author(s):

Copyright 2012 the GlaxoSmithKline group of companies. All rights reserved. Unauthorised copying or use of this information is prohibited.


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Indication Studied: Early stage, HER2 positive breast cancer

Initiation Date: [31-03-2009]

Completion Date: [16-04-2012]

Early Termination Date: NA

Earlier CSRs NA

Sponsor Signatory: (and Medical Officer)

[Director Clinical Development] [Project Physician Leader for Lapatinib] Global Oncology, United States of America] [GlaxoSmithKline]

This study was performed in compliance with Good Clinical Practices and GlaxoSmithKline Standard Operating Procedures for all processes involved, including the archiving of essential documents.

TABLE OF CONTENTS Page

ABBREVIATIONS ................................................................................................... ETHICS AND GOOD CLINICAL PRACTICE .......................................................... 1. INTRODUCTION ............................................................................................... 2. STUDY OBJECTIVE(S) ..................................................................................... 3. INVESTIGATIONAL PLAN ................................................................................

3.1. Study Design ................................................................................................. 3.2. Protocol Amendment(s) ................................................................................. 3.3. Study Assessments and Procedures .............................................................

3.3.1. Safety Assessments ........................................................................... 3.3.2. DNA preparation and Genotyping Methodology .................................

3.4. Statistical Analyses........................................................................................ 4. STUDY POPULATION ......................................................................................

4.1. Populations Analyzed .................................................................................... 4.2. Demographics and Baseline Characteristics .................................................

5. RESULTS .......................................................................................................... 6. DISCUSSION AND CONCLUSIONS .................................................................

6.1. Discussion ..................................................................................................... 6.2. Conclusions ...................................................................................................

7. REFERENCES .................................................................................................. DATA SOURCE TABLES AND FIGURES ..............................................................

Table 1: Case status (ALT >3x ULN) by treatment arm and MHC genotype data availability ................................................................................................

Table 2: Patient characteristics in lapatinib treatment study arm by MHC genotype data availability ........................................................................................

Table 3: Patient characteristics in lapatinib treatment Study arm by strict ALT >3x ULN case and control status ....................................................................

Table 4: Strictly defined ALT >3 x ULN cases and controls and MHC genotypes among lapatinib-treated subjects .............................................................

Table 5: Linkage disequilibrium among MHC genetic variants ............................... Table 6: Pairwise logistic regression of each MHC genetic variant adjusted for

another MHC genetic variant for strictly defined ALT >3xULN casesand controls ....................................................................................................

Table 7: Performance metrics for MHC genetic variants and broadly defined cases and non-cases among lapatinib-treated subjects ..........................

Table 8: Lapatinib-treated Combined Cases: MHC Genotype and Liver Chemistry Summaries ...............................................................................................

Figure 1: Cumulative Incidence of ALT >3x in Strict Cases and Controls by MHC Genotype Carrier .....................................................................................

Figure 2: Cumulative Incidence of ALT >3x in Strict Cases and Controls by MHC Genotype Carrier .....................................................................................

Figure 3: Flow diagram of analysis populations for ALT >3X ULN ..........................

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CONFIDENTIAL 2012N141241_00EGF114471_00

CONFIDENTIAL 2012N141241_00 EGF114471

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ABBREVIATIONS

AE Adverse Event ALT Alanine aminotransferase CFR Code of Federal Regulations CD4 Cluster of Differentiation 4 CI Confidence Interval CNS Central Nervous System CTD Common Technical Document eCRF Electronic Case Report Form GCP Good Clinical Practice GCSP Global Clinical Safety and Pharmacovigilance GSK GlaxoSmithKline HER2 Human Epidermal Growth Factor Receptor 2 HLA Human Leukocytic Antigen ICH International Conference on Harmonisation LD Linkage Disequilibrium MBC Metastatic Breast Cancer MHC Major Histocompatibility Complex MedDRA Medical Dictionary for Regulatory Activities NCI CTCAE

National Cancer Institute's Common Terminology Criteria for Adverse Events

NPV Negative Predictive Value OR Odds Ratio PPV Positive Predictive Value SAE Serious Adverse Event SOP Standard Operating Procedure TBL Total bilirubin TEACH Tykerb Evaluation After Chemotherapy TNXB Tenascin XB ULN Upper Limit of Normal Trademark Information

Trademarks of the GlaxoSmithKline group of companies

Trademarks not owned by the GlaxoSmithKline group of companies

TYKERB None TYVERB

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ETHICS AND GOOD CLINICAL PRACTICE

EGF114471 is a non-interventional, pharmacogenetic substudy of the clinical trial EGF105485 (TEACH). EGF105485 was conducted in accordance with ICH GCP and all applicable subject privacy requirements, and, the ethical principles that are outlined in the Declaration of Helsinki 2008. The clinical trial protocol included blood sample DNA collection and was approved by independent ethics committee or institutional review boards. Informed consent for pharmacogenetic investigation was obtained in addition to the subject’s consent to participate in the EGF105485 clinical study.

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1. INTRODUCTION

Lapatinib (TYKERB™/TYVERB™) is approved for use in patients with metastatic breast cancer (MBC) whose tumours over-express HER2, in combination with capecitabine for patients who have received previous therapy, including anthracycline, a taxane and trastuzumab and in combination with letrozole for first line treatment of postmenopausal women with hormone receptor-positive MBC. In addition, clinical trials are ongoing to evaluate lapatinib in combination with trastuzumab in MBC and also in adjuvant treatment of earlier stage breast cancer. Hepatobiliary abnormalities, including isolated serum alanine-aminotransferase (ALT) elevation (>3x ULN) have been observed in lapatinib-treated patients. In addition, grade 3 isolated ALT elevation (ALT>5x ULN, NCI Common Terminology Criteria for Adverse Events, v3.0) and serious liver injury with hyperbilirubinemia (possible Hy’s Law cases) have been observed to occur in <3% and <1% respectively, of cancer patients receiving lapatinib treatment [Moy, 2009].

Previous pharmacogenetic investigations of lapatinib-associated hepatobiliary abnormalities were conducted using the laboratory and clinical data from studies of lapatinib in patients with MBC [Spraggs, 2011]. A two-stage strategy was used, with the first stage being exploratory to identify, and the second stage following-up to confirm specified markers associated with liver chemistry changes during lapatinib treatment. The first stage analyzed twelve MBC trials (901 subjects consenting for pharmacogenetic investigation) evaluating lapatinib as monotherapy or as a component of various chemotherapy combinations. The second stage analyzed a single phase III trial (374 subjects consenting for pharmacogenetic investigation) evaluating lapatinib plus letrozole in post menopausal hormone receptor-positive MBC. The confirmatory second stage found four Major Histocompatibility Complex (MHC) region genetic variants associated with isolated elevated serum ALT during lapatinib treatment. These comprised three common alleles in Human Leukocytic Antigen (HLA) genes (HLA-DRB1*07:01, -DQA1*02:01 and -DQB1*02:02) and a single nucleotide polymorphism (rs12153855) in an adjacent gene, tenascin XB (TNXB) [Spraggs, 2011]. These four genetic variants are often inherited jointly, are correlated, and consistent with a single genetic association signal. Further investigation has extended these specified HLA associations with isolated ALT elevations to lapatinib-treated patients who experienced serious liver injury with hyperbilirubinaemia (possible Hy’s Law cases) [Spraggs, 2012]. These findings suggest immune-mediated damage of liver tissue, restricted to a small proportion of patients who carry HLA-DRB1*07:01 and -DQA1*02:01 alleles.

These retrospectively conducted investigations from multiple clinical trials suggested a robust association of the specified MHC genetic variants with liver injury during lapatinib treatment and their potential for clinical utility. To provide a higher level of evidence pertaining to the use of the specified MHC genetic variants as potential safety risk biomarkers, a prospectively defined pharmacogenetic analysis was conducted retrospectively in EGF105485 (TEACH, A Randomised, Double-blind, Multicenter, Placebo-controlled Study of Adjuvant Lapatinib in Women with Early Stage ErbB2 Overexpressing Breast Cancer). Where country-specific pharmacogenetic approval was achieved, DNA samples were collected prospectively from the large majority of participants to minimize selection bias. This pharmacogenetic investigation had a pre-defined hypothesis and analysis plan and was determined to have sufficient power to

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detect variant association odds ratios smaller than those reported in the confirmatory study.

2. STUDY OBJECTIVE(S)

The primary aims of this prospectively defined, retrospectively conducted pharmacogenetic analysis in EGF105485 (TEACH) were to: (1) determine the association of the previously confirmed genetic variants located in the MHC region with signals of hepatotoxicity among subjects treated with lapatinib from EGF105485 (TEACH), and (2) to determine the predictive characteristics of these associations for the clinical management of liver safety in this study population of patients with HER2 over-expressing early stage breast cancer.

3. INVESTIGATIONAL PLAN

3.1. Study Design

EGF114471 is a non-interventional, prospectively planned, retrospectively conducted pharmacogenetic substudy of the clinical trial EGF105485 (TEACH). DNA samples were collected from subjects participating in TEACH and associations between four previously confirmed MHC genetic variants and serum liver chemistry changes were evaluated.

EGF105485 (TEACH) is a phase III, randomized, double-blind, multicenter, placebo-controlled study of adjuvant lapatinib in women with early-stage HER2 overexpressing breast cancer. Eligible women must have completed primary neoadjuvant or adjuvant chemotherapy and must have no clinical or radiographic evidence of disease at the time of study entry. The primary objective of the clinical study is to determine whether adjuvant therapy with lapatinib will improve disease free survival. Secondary objectives include overall survival, recurrence-free survival, distant recurrence-free survival, CNS recurrence-free survival, and quality of life measures. Relevant to this pharmacogenetic study, safety objectives include determining the qualitative and quantitative toxicities associated with oral lapatinib administered daily versus placebo.

3.2. Protocol Amendment(s)

Relevant to this pharmacogenetic substudy, following a review of all hepatobiliary events reported across the entire lapatinib clinical development program, Amendment 05 was implemented for EGF105485 on 21May2008. This amendment increased the frequency of standard chemistry testing to every six weeks, added stopping rules and follow-up criteria based on livery chemistry results, and widened the visit windows in the follow-up phase of the study [Reference EGF105485 Amendment 07].

3.3. Study Assessments and Procedures

3.3.1. Safety Assessments

Serum alanine aminotransferase (ALT) and total bilirubin (TBL) measurements were performed by local institutional laboratories and by central laboratories. These values were converted to the multiples of ‘upper limit of normal’ (ULN) by dividing the

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laboratory values by the institutional laboratory-specific upper limit of normal values. Liver chemistry tests were initially performed in all subjects every three months during treatment, however with Protocol Amendment 05 in May 2008, liver chemistry testing was revised to every six weeks, with weekly monitoring if ALT >3x ULN and additional criteria outlined in the algorithm for liver chemistry stopping rules and follow-up criteria are met [Reference EGF105485 Amendment 07].

3.3.2. DNA preparation and Genotyping Methodology

Venous blood was collected into an EDTA vacutainer from subjects who provided consent for pharmacogenetic investigation. Germline DNA was extracted using the Qiagen QiAMP DNA Blood Kit by one of three central laboratories: Quest Diagnostics (Van Nuys, CA USA and Heston, UK) or Adicon Clinical Laboratories inc. (Shanghai, China). The concentration and quality of the isolated DNA were verified by spectrophotometry and agarose gel electrophoresis by the vendors.

Classical 4-digit HLA genotyping was performed for HLA-DQA1, HLA-DQB1, and HLA-DRB1 by Laboratory Corporation of America (Burlington, NC, USA), Beijing Blood Bank (Beijing, China), Histogenetics (Ossining, NY, USA) and at GlaxoSmithKline using the LABType SSO Typing Test (One Lambda, Canoga Park, CA, USA). Genotype data for TNXB rs12153855 was generated using the Illumina Human 1M-Duo beadchip array by Expression Analysis (Durham, NC, USA) and ShanghaiBio Corporation (Shanghai, China).

3.4. Statistical Analyses

Statistical analyses were conducted independently by Professor PhD and ( under

the Collaborative Research Trial arrangements for EGF105485 (TEACH). In collaboration with GlaxoSmithKline, Professor designed the prospective analysis plan and received only the clinical and genotype data from GlaxoSmithKline necessary to conduct the pre-defined analyses.

To achieve study objectives, a series of case-control analyses related to liver chemistry elevations were performed for each of the four specified MHC region genetic variants. Binary carrier status (yes vs. no) was defined for the analysis of each of the following:

1. TNXB rs12153855 CC/CT genotype

2. HLA-DRB1*07:01 carrier (heterozygous or homozygous)

3. HLA-DQA1*02:01 carrier (heterozygous or homozygous)

4. HLA-DQB1*02:02 carrier (heterozygous or homozygous)

The primary analyses focused on cases that had on-treatment elevated ALT. The terms ‘case’ and ‘control’ are used for the convenience of referring to subjects who had, or did not have, elevated liver chemistries, but this study is based on a prospective clinical trial cohort, which should not be confused with typical case-control studies that are based on retrospective definitions of risk factors. Because of the prospective design, the study is able to estimate, free of retrospective biases, the frequency of cases (i.e., subjects with

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elevated liver chemistries) within each MHC marker categories, along with odds ratios (OR), positive predictive value (PPV) and negative predictive value (NPV) to estimate the effects of the MHC markers.

Since ALT elevations can occur for reasons other than lapatinib treatment, strict case and control definitions were utilized for determining the genetic effects and attempting to isolate lapatinib-treatment specific effects. In addition, broad case and non-case definitions were used to determine potential clinical utility in all subjects exposed to lapatinib who provided a DNA sample and had liver chemistry data available. These definitions were consistent with those used for the previous studies.

Strict ALT cases were defined as lapatinib-treated subjects who had a baseline ALT measurement within the upper limit of normal range (≤1 x ULN) and one or more on-treatment ALT measurement >3 x ULN during the course of treatment. Strict ALT controls were subjects exposed to lapatinib for at least thirteen weeks, who had baseline and all of their on-treatment ALT measurements within the normal range. Previous analyses of lapatinib breast cancer trials showed that by thirteen weeks, approximately 50% of the ALT cases had their first ALT elevation >3xULN and this was used for consistency with prior analyses.

For determination of measures of clinical utility, any patient in EGF105485 who had one or more on-treatment ALT measurement >3 x ULN during the course of treatment was considered a broad ALT case, and all individuals with at least one on-treatment laboratory measure, who are not broad ALT cases are classified as broad non-cases.

To evaluate the association of the specified MHC variants with case-control status, logistic regression in the R and SAS statistical software packages were used to estimate ORs and their confidence intervals. Because of the relatively small number of cases, potential covariates were screened one at a time, using backward selection to reduce the number of levels of covariates, in order to minimise the number of adjusting covariates. Categorical measures were compared with Pearson’s chi-square statistic, and quantitative measures were compared with the nonparametric Wilcoxon rank sum statistic. To compare time to event data (e.g., the time at which a subject first becomes a case) between MHC variant carriers versus non-carriers, the Cox proportional hazards model was used to account for censored data. That is, a subject was censored at the time of last laboratory measurement if their ALT value never exceeded 3x ULN while on treatment or up to 30 days after the end of treatment.

For further details on analysis methods, refer to the Reporting and Analysis Plan. [Reference RAP]

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4. STUDY POPULATION

4.1. Populations Analyzed

A total of 3146 subjects from the EGF105485 Safety Population were available for analyses: 1572 subjects randomized to lapatinib, and 1574 randomized to placebo. This pharmacogenetic substudy included 2453 subjects with available genetic data: 1194 subjects (76%) in the lapatinib arm, and 1259 subjects (80%) in the placebo arm. Of the 1194 lapatinib-treated subjects with MHC genotype data available, clinical liver chemistry data was available for designation of broad ALT case vs. non-case status in 1108 subjects and strict ALT case vs. control status in 846 subjects [Figure 1].

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Figure 1 Flow diagram of pharmacogenetic analysis populations for ALT greater than 3x ULN

Safety Population (N=3,146)

Lapatinib (N=1,572)

No MHC Genotype Data

Available (N=378)

MHC Genotype Data Available

(N=1,194)

Broad Case (N=37)

Strict Case (N=34)

Neither2 (N=3)

Broad Non-Case (N=1,071)

Strict Control (N=812)

Neither3(N=257)

Missing Data4

(N=2)

Missing Data1

(N=86)

Placebo (N=1,574)

No MHC Genotype Data

Available (N=315)

MHC Genotype Data Available

(N=1,259)

Broad Case (N=6)

Strict Case (N=5)

Neither2 (N=1)

Broad Non-Case (N=1,228)

Strict Control (N=1,076)

Neither3 (N=149)

Missing Data4

(N=3)

Missing Data1

(N=25)

1Missing on-treatment ALT measures, 2Not a strict case since baseline ALT measure is elevated >1xULN, 3Not a strict control since treatment duration is <13 weeks, 4Missing baseline ALT measurement, but on-treatment measure(s) available

Data Source Figure 3

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Isolated ALT elevation cases, using either the strict or broad definitions, are seen at higher rates in lapatinib-treated subjects, than those in the placebo arm [Table 1].

Table 1 Case status by treatment arm and MHC genotype data availability

Lapatinib with MHC Genotype Data Available (N=1194)

Lapatinib with no MHC Genotype Data Available (N=378)

Placebo with MHC Genotype Data Available (N=1259)

Placebo with no MHC Genotype Data Available (N=315)

Strictly defined ALT case status

Case 34 (2.8%) 6 (1.6%) 5 (0.4%) 1 (0.3%) Control 812 (68.0%) 228 (60.3%) 1076 (85.5%) 245 (77.8%) Neither 260 (21.8%) 87 (23.0%) 150 (11.9%) 39 (12.4%) Missing Data 88 (7.4%) 57 (15.1%) 28 (2.2%) 30 (9.5%) Broadly defined ALT case status

Case 37 (3.1%) 6 (1.6%) 6 (0.5%) 4 (1.3%) Non-Case 1071 (89.7%) 317 (83.9%) 1228 (97.5%) 283 (89.8%) Missing Data 86 (7.2%) 55 (14.6%) 25 (2.0%) 28 (8.9%) Data Source Table 1

4.2. Demographics and Baseline Characteristics

Demographic and baseline characteristics were assessed in the lapatinib-treatment arm to identify any imbalances between the subjects with MHC genotype data available, compared to those without. The two populations were well balanced on most factors (p>0.05). Significant differences (p<0.001) were observed in HER2 FISH status (but not HER2 ICH status, p=0.12) and self-reported racial background. The majority (66%) of subjects with MHC genotype data available are categorized as “White – Not Hispanic”, however other ethnic groups, primarily the “White –Hispanic” subjects are observed at higher percentages in the group with no MHC genotype data available. [Reference Data Source Table 2]

The same set of demographic and baseline characteristics were assessed in the lapatinib-treated strict ALT cases vs. controls with MHC genotype data available. The strict ALT cases were significantly older (median=56.5 years) than strict controls (median=51.0 years, p=0.001), while the remaining variables were well-balanced between the two groups (p>0.05). [Reference Data Source Table 3]

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5. RESULTS

Table 2 describes the frequency of strict cases and controls between carriers and non-carriers of the four MHC variants arranged in their genomic order (TNXB-DRB1-DQA1-DQB1) in the lapatinib treatment study arm. Carriers of each of the four specified MHC variants had greater frequencies of strict ALT cases than their respective non-carriers, with the largest odds ratios of approximately 20 for HLA-DQA1*02:01 and -DRB1*07:01. The flanking variants, TNXB and HLA-DQB1*02:02, had smaller but still, statistically significant associations. An analysis adjusted for covariates of age (dichotomized at the median of 52 years) and race (dichotomized as self-reported Asians vs. all others) had little influence on the magnitude of the marker effects in terms of odds ratios or p values (data not presented).

Table 2 Strictly defined ALT greater than 3x ULN cases and controls and MHC genotypes among lapatinib-treated subjects

MHC Marker

Risk Genotype Categories Cases Controls

Count % Count % OR (95% CI) p-value

TNXB rs12153855

CC/CT genotype 17 11.6 130 88.4 5.23 (2.60-10.51) 8.4e-6

non-carrier 17 2.4 680 97.6 1.00 (reference)

total 34 810

HLA-DRB1 *07:01

carrier (heterozygous or homozygous)

28 15.5 153 84.5 19.98 (8.13 – 49.10) 1.4e-14


total 34 808 HLA-DQA1 *02:01


28 15.5 153 84.5 19.95 (8.12 – 49.02) 1.5e-14


total 34 807

HLA-DQB1 *02:02


22 15.1 124 84.9 10.08 (4.86 – 20.90) 4.0e-10


total 34 806 Data Source Table 4

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In contrast to Table 2, for the six subjects receiving placebo who were classified as strict ALT cases, five provided DNA and none were carriers of any of the specified HLA alleles of interest (data not shown).

Previous studies have shown the four MHC variants to be highly correlated and this was confirmed in the present study with very high values of linkage disequilibrium (LD) between HLA-DRB1*07:01 and -DQA1*02:01 [Data Source Table 5]. Linkage disequilbrium between TNXB rs12153855 and the other variants was not as extreme, but still relatively large. Pair-wise conditional regression analysis [Data Source Table 6] showed the effects of TNXB rs12153855 and HLA-DQB1*02:02 were no longer significant when HLA-DQA1*02:01 or -DRB1*07:01 were included as covariates. In contrast, the effects of HLA-DQA1*02:01 and -DRB1*07:01 remained statistically significant (p<1e-6) when adjusting for the other two MHC markers. HLA-DQA1*02:01 and –DRB1*07:01 were not compared since they are so highly correlated that a logistic regression could not be fitted. These results suggest that the association of MHC markers with strict ALT case-control status is caused primarily by either HLA-DQA1*02:01 or -DRB1*07:01.

Extensive data on HLA carriage population frequencies is available from the Allele Frequency Net Database [Allele, 2011]. Consistent with this database, allele carriage of HLA-DQA1*02:01 and -DRB1*07:01 in EGF105485 (TEACH) was common in most racial groups, including White/Caucasians (25%, n=1735) and East Asians (15%, n=353). Although not represented adequately in the EGF105485 (TEACH) study population, it is noted from the Allele Frequency Net Database [Allele, 2011] that HLA-DQA1*02:01 and -DRB1*07:01 allele carriage is lower in subjects of some ethnic groups, i.e Japanese heritage (<1%) and Pacific Island heritage (<7%) (data not shown).

Data Source Figure 1 and Data Source Figure 2 describe cumulative frequency of ALT case presentation over time in the strict case-control individuals by MHC allele carriage for lapatinib- and placebo-treated subjects, respectively. All four MHC variants show that carriage of the specified MHC risk alleles account for the ALT elevation caused by lapatinib, with the rate of ALT case presentation in non-carriers being comparable to the background levels observed in the placebo arm. In addition, accumulation of ALT strict cases for lapatinib-treated specified HLA carriers increased and did not appear to level off during the duration of study treatment. The results from HLA-DRB1*07:01 are presented below [Figure 2], and it is noted the results for HLA-DQA1*02:01 are nearly identical.

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Figure 2 Cumulative Incidence of ALT greater than 3x ULN in Strict Cases and Controls, by HLA-DRB1*07:01 allele carriage status in the lapatinib (left panel) and placebo (right panel) arms

Data Source Figure 1, Data Source Figure 2 Clinical utility measures, using broadly defined cases and non-cases, for HLA-DQA1*02:01 and -DRB1*07:01 allele carriage as predictive markers for the liver safety risk of lapatinib treatment for ALT elevation of >3xULN, provided high odds ratios (OR, 14), high Negative Predictive Values (NPV, 99.1%) and moderate Positive Predictive Values (PPV, 12%). Compared to an overall study population risk of 3% (Data Source Table 1) for developing an ALT elevation (>3x ULN) during lapatinib treatment, there is a much lower risk (1-NPV, 0.9%) in non-carriers of HLA-DQA1*02:01 and -DRB1*07:01 alleles, while the risk for the carriers of the specified HLA allele experiencing such an elevation is increased to 12% (PPV). [Data Source Table 7]

Whilst on-treatment ALT elevation of >3x ULN is a recognised liver safety signal [FDA, 2009], thresholds of ALT >8x ULN in metastatic breast cancer and >5x ULN in adjuvant breast cancer clinical trials are considered more serious liver injury that require treatment discontinuation for affected subjects. Therefore, HLA-DQA1*02:01 and -DRB1*07:01 allele carriage was examined for more stringent broad ALT case thresholds [Table 3]. The association was maintained such that for ALT elevation >5x ULN (NCI CTC AE v4, Grade 3 ALT elevation), which occurred in 23 cases, OR was 18, NPV was 99.5% and PPV was 8%. For an ALT elevation threshold of >10x ULN, eight cases were identified from the lapatinib-treated group that provided DNA, and all eight cases were carriers of the specified HLA alleles (OR not computed). This group with the most serious isolated ALT elevations attained a NPV of 100% and a PPV of 3%.

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Table 3 Performance metrics for MHC genetic variants and broadly defined cases and non-cases among lapatinib-treated subjects

MHC Marker Cases Non-Cases OR (95% CI†) Sensitivity (95% CI‡)

Positive Predictive Value (95% CI‡)

Specificity (95% CI‡)

Negative Predictive Value (95% CI‡)

HLA-DRB1 *07:01

ALT >3xULN 37 1067 14.12 (6.36, 31.32) 78.4 (61.8, 90.2) 11.7 (8.0, 16.4) 79.6 (77.0, 82.0) 99.1 (98.2, 99.6)

ALT >5xULN 23 1081 17.77 (5.99, 52.75) 82.6 (61.2, 95.1) 7.7 (4.7, 11.8) 78.9 (76.4, 81.3) 99.5 (98.8, 99.9)

ALT >10xULN 8 1096 †† 100.0 (63.1, 100.0) 3.2 (1.4, 6.3) 78.2 (75.6, 80.6) 100.0 (99.6, 100.0)

HLA-DQA1 *02:01

ALT >3xULN 37 1065 14.08 (6.35, 31.24) 78.4 (61.8, 90.2) 11.7 (8.0, 16.4) 79.6 (77.0, 82.0) 99.1 (98.2, 99.6)

ALT >5xULN 23 1079 17.73 (5.97, 52.63) 82.6 (61.2, 95.1) 7.7 (4.7, 11.8) 78.9 (76.3, 81.3) 99.5 (98.8, 99.9)

ALT >10xULN 8 1094 †† 100.0 (63.1, 100.0) 3.2 (1.4, 6.3) 78.2 (75.6, 80.6) 100.0 (99.6, 100.0)

†Asymptotic confidence interval for the odds ratio (OR) ‡Exact binomial confidence interval ††Note OR was not computed because all cases were carriers of the variant Data Source Table 7

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Furthermore, eight cases of concurrent ALT/AST and total bilirubin (TBL) elevation (possible Hy’s Law cases) were observed during lapatinib treatment in EGF105485 (TEACH). [Data Source Table 8] Seven of these eight subjects provided DNA. One subject with DNA (9992) had elevations in AST, but their corresponding ALT measure did not exceed the >3x ULN threshold. Of the remaining six individuals, five were carriers of the HLA-DQA1*02:01 and –DRB1*07:01 alleles.

6. DISCUSSION AND CONCLUSIONS

6.1. Discussion

This study provides prospective validation of the previously confirmed, retrospective associations between lapatinib-associated ALT elevation and serious liver injury and the highly correlated HLA alleles DQA1*02:01 and DRB1*07:01. This represents a higher level of evidence than is obtainable through retrospective evaluations [Mandrekar, 2009]. The randomised, treatment-blinded study design of EGF105485 (TEACH), with collection of blood samples for genotyping during study assessments and before study completion and unblinding, meant that neither assigned treatment (lapatinib or placebo) nor HLA status influenced treatment course or evaluation of the liver chemistry changes.

The magnitude of the HLA association for ALT elevation for strictly defined ALT cases >3x ULN and controls (odds ratio 20) was greater than previously observed in metastatic breast cancer studies [Spraggs, 2011]. This may reflect heterogeneity in the previous studies, which utilised pooled data across clinical trials with different combinations of lapatinib treatment for metastatic breast cancer, in contrast to the present large, lapatinib monotherapy treatment study in early stage breast cancer. It is noted that for higher ALT safety thresholds (>5x ULN), magnitudes of association and NPV increased for lapatinib-treated patients from both metastatic breast cancer trials [Spraggs, 2011] and the present, early stage breast cancer trial.

This Class II HLA locus associated with on-treatment ALT elevation is the same as that described for the investigational drug ximelagatran [Kindmark, 2008]. HLA allele associations have been observed for a range of drug–induced serious adverse events, including liver injury, serious skin reactions and hypersensitivity reactions [Phillips, 2010]. The association of lapatinib-induced hepatotoxicity with a Class II HLA locus suggests an immune-mediated attack on hepatocytes involving CD4 positive T cells [Bharadwaj, 2012]. The fact that the majority (1-PPV) of specified HLA allele carriers appear to tolerate lapatinib without ALT elevation during the one year treatment period, is consistent with the hypothesis that restricted HLA expression is necessary, but not sufficient to elicit this adverse event.

Comparison of the cumulative incidence of ALT elevation between lapatinib and placebo subject groups showed that carriage of the specified HLA alleles was sufficient to account for ALT elevation above background, non-lapatinib levels. Whilst the association

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demonstrated very high NPV, suitable for a safety risk predictive biomarker, the moderate PPV is a consequence of the common carriage of the specified HLA alleles in the general population and the relatively low incidence of serious liver injury during lapatinib treatment. Prospective, specified HLA allele testing in lapatinib-treated metastatic breast cancer patients would result in a high false positive rate, with a substantially greater proportion of patients identified as at risk of liver injury than would actually occur. However, the present prospective validation of the previous findings, plus the high NPV suggest scope for HLA-DQA1*02:01 and -DRB1*07:01 alleles as a biomarker to enable identification and appropriate clinical management of patients who have the highest risk of lapatinib-induced liver injury. Awareness of these findings and the established widespread availability of HLA testing could potentially support clinical management of patients during lapatinib treatment.

6.2. Conclusions

This pharmacogenetic study using subjects from EGF105485 (TEACH) has prospectively validated the associations of HLA-DQA1*02:01 and -DRB1*07:01 allele carriage with ALT elevation and serious liver injury that occurs during lapatinib treatment.

This robust association suggests a mechanism of lapatinib-specific, immune-mediated cell damage, targeted to the liver.

Widespread awareness of these findings could potentially support clinical management of patients during lapatinib treatment.

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7. REFERENCES

Bharadwaj M, Illing P, Theodosis A, Purcell AW, Rossjohn J, McCluskey J. Drug hypersensitivity and human leukocytic antigens of the Major Histocompatibility Complex. Ann Rev Pharmaco Toxicol, 2012;52:401-431.

FDA Guidance for Industry. Drug-induced liver injury: Pre-marketing clinical evaluation 2009. Available at http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM174090.pdf. Accessed July 3 2012/

Kindmark A, Jawaid A, Habron CG, et al. Genome-wide pharmacogenetic investigation of a hepatic adverse event without clinical signs of immunopathology suggests an underlying immune pathogenesis. Pharmacogenomics J, 2008;8:186-195.

Mandrekar SJ, Sargeant DJ. Clinical trial designs for predictive biomarker validation: theoretical considerations and practical challenges. J Clin Oncol, 2009;27: 4027-4034.

Moy B, Rappold E, Williams, L et al. Hepatobiliary abnormalities in patients with metastatic breast cancer treated with lapatinib. J Clin Oncol. 2009;27:1043.

Phillips EJ, Mallal SA. Pharmacogenetics of drug hypersensitivity. Pharmacogenomics, 2010;11: 973-987.

Spraggs CF, Budde LR, Briley LP, et al. HLA-DQA1*02:01 is a major risk factor for lapatinib-induced hepatotoxicity in women with advanced breast cancer. J Clin Oncol, 2011;29:667-673.

Spraggs CF, Parham LR, Hunt CM, Dollery CT. Lapatinib-induced liver injury characterised by Class II HLA and Gilbert’s syndrome genotypes. Clin Pharmac Ther, 2012;91:647-652.

The Allele Frequency Net Database 2011. Available at http://www.allelefrequencies.net/ Accessed July 3 2012

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Table 1: Case status (ALT >3x ULN) by treatment arm and MHC genotype data availability


Lapatinib with no MHC Genotype Data Available (N=378)

Placebo with MHC Genotype Data Available (N=1259)

Placebo with no MHC Genotype Data Available (N=315)

Strictly defined ALT case status

Case 34 (2.8%) 6 (1.6%) 5 (0.4%) 1 (0.3%)

Control 812 (68.0%) 228 (60.3%) 1076 (85.5%) 245 (77.8%)

Neither 260 (21.8%) 87 (23.0%) 150 (11.9%) 39 (12.4%)

Missing Data 88 (7.4%) 57 (15.1%) 28 (2.2%) 30 (9.5%)

Broadly defined ALT case status

Case 37 (3.1%) 6 (1.6%) 6 (0.5%) 4 (1.3%)

Non-Case 1071 (89.7%) 317 (83.9%) 1228 (97.5%) 283 (89.8%)

Missing Data 86 (7.2%) 55 (14.6%) 25 (2.0%) 28 (8.9%)

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Table 2: Patient characteristics in lapatinib treatment study arm by MHC genotype data availability


Lapatinib, no MHC Genotype Data Available (N=378) p value

Age (in years) 0.8472 Mean 51.76 51.68 Median 52.00 51.50 Range (25.00-87.00) (24.00-77.00) Race 1.02e-13 African American/African Heritage – Hispanic 0 (0)% 11 (2.9%) African American/African Heritage - Not Hispanic 24 (2.0%) 6 (1.6%) American Indian or Alaskan Native 47 (3.9%) 13 (3.4%) Asian - Central/South Asian Heritage 15 (1.3%) 4 (1.1%) Asian - East Asian Heritage 174 (14.6%) 62 (16.4%) Asian - Japanese Heritage 1 (0.1%) 0 (0.0%) Asian - South East Asian Heritage 61 (5.1%) 20 (5.3%) Mixed race 16 (1.3%) 3 (0.8%) Native Hawaiian or Other Pacific Islander 5 (0.4%) 0 (0.0%) White - Arabic/North African Heritage 0 (0.0%) 2 (0.5%) White - White/Caucasian/European Heritage – Hispanic 60 (5.0%) 54 (14.3%) White - White/Caucasian/European Heritage – Not Hispanic 791(66.2%) 203 (53.7%) Stage at initial diagnosis code 0.5652 1 209 (17.5%) 75 (19.8%) 2 688 (57.6%) 209 (55.3%) 3 297 (24.9%) 94 (24.9%) T-stage at initial diagnosis code 0.7708 T1 401 (33.6%) 133 (35.2%) T2 606 (50.8%) 192 (50.8%) T3 112 (9.4%) 36 (9.5%) T4 65 (5.4%) 15 (4.0%) TX 10 (0.8%) 2 (0.5%) Estrogen receptor status 0.2053 Negative 557 (46.6%) 175 (46.3%) Positive 637 (53.4%) 202 (53.4%) Unknown 0 (0.0%) 1 (0.3%) Progesterone receptor status 0.4730

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Negative 656 (54.9%) 200 (52.9%) Positive 535 (44.8%) 178 (47.1%) Unknown 3 (0.3%) 0 (0.0%) ErbB2(Her2/neu) ICH status 0.1249 Missing 1 1 0 0 (0.0%) 1 (0.3%) 1+ 9 (0.8%) 0 (0.0%) 2+ 168 (14.1%) 45 (11.9%) 3+ 960 (80.5%) 313 (83.0%) Unknown 56 (4.7%) 18 (4.8%) ErbB2(Her2/neu) FISH status 0.0008 Negative 19 (1.6%) 19 (5.0%) Positive 552 (46.2%) 169 (44.7%) Unknown 623 (52.2%) 190 (50.3%) Baseline ALP (x ULN) 0.4393 Mean 0.62 0.63 Median 0.60 0.60 Range (0.21-1.92) (0.27-1.63) Baseline ALT (x ULN) 0.8906 Mean 0.43 0.42 Median 0.35 0.35 Range (0.05-2.83) (0.13-2.31) Baseline AST (x ULN) 0.3417 Mean 0.53 0.53 Median 0.48 0.48 Range (0.12-3.57) (0.20-2.65) Baseline BILI (x ULN) 0.2211 Mean 0.42 0.40 Median 0.36 0.36 Range (0.14-1.64) (0.14-1.23) p-value is for Wilcoxon rank sum test for continuous measures and chi-square test for all categorical variables.

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Table 3: Patient characteristics in lapatinib treatment Study arm by strict ALT >3x ULN case and control status

Missing Data

(N=88) Neither (N=260)

Case (N=34)

Control (N=812) p value

Age (in years) 0.0010

Mean 53.330 52.035 56.912 51.287

Median 54.000 52.000 56.500 51.000

Range (32.00-74.00) (25.00-77.00) (40.00-72.00) (25.00-87.00)

Race 0.1891

African American/African Heritage

– Hispanic

0 0 0 0

African American/African Heritage

– Not Hispanic

1 9 0 (0.0%) 14 (1.7%)

American Indian or Alaskan Native 0 19 2 (5.9%) 26 (3.2%)

Asian - Central/South Asian Heritage 0 4 0 (0.0%) 11 (1.4%)

Asian - East Asian Heritage 6 29 1 (2.9%) 138 (17.0%)

Asian - Japanese Heritage 0 0 0 (0.0%) 1 (0.1%)

Asian - South East Asian Heritage 5 19 1 (2.9%) 36 (4.4%)

Mixed race 1 3 0 (0.0%) 12 (1.5%)

Native Hawaiian or Other Pacific Islander 0 2 0 (0.0%) 3 (0.4%)

White - White/Caucasian/European Heritage

– Hispanic

2 12 5 (14.7%) 41 (5.0%)

White - White/Caucasian/European Heritage

– Not Hispanic

73 163 25 (73.5%) 530 (65.3%)

Stage at initial diagnosis 0.5920

1 19 49 6 (17.6%) 135 (16.6%)

2 50 145 22 (64.7%) 471 (58.0%)

3 19 66 6 (17.6%) 206 (25.4%)

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Missing Data


Case (N=34)


T-stage at initial diagnosis code 0.5706

T1 35 82 14 (41.2%) 270 (33.3%)

T2 42 133 16 (47.1%) 415 (51.1%)

T3 6 24 4 (11.8%) 78 (9.6%)

T4 4 19 0 (0.0%) 42 (5.2%)

TX 1 2 0 (0.0%) 7 (0.9%)

Estro/Oestr receptor status 0.5459

Negative 31 121 18 (52.9%) 387 (47.7%)

Positive 57 139 16 (47.1%) 425 (52.3%)

Progesterone receptor status 0.8934

Negative 45 141 20 (58.8%) 450 (55.4%)

Positive 43 118 14 (41.2%) 360 (44.3%)

Unknown 0 1 0 (0.0%) 2 (0.2%)

ErbB2(Her2/neu) ICH status 0.7462

Missing 0 0 0 1

1+ 0 5 0 (0.0%) 4 (0.5%)

2+ 6 37 7 (20.6%) 118 (14.5%)

3+ 80 205 25 (73.5%) 650 (80.1%)

Unknown 2 13 2 (5.9%) 39 (4.8%)

ErbB2(Her2/neu) FISH status 0.6375

Negative 6 2 1 (2.9%) 10 (1.2%)

Positive 20 124 15 (44.1%) 393 (48.4%)

Unknown 62 134 18 (52.9%) 409 (50.4%)

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Missing Data


Case (N=34)


Baseline ALP 0.7962

Mean 0.656 0.661 0.604 0.602

Median 0.620 0.632 0.608 0.576

Range (0.31-1.92) (0.22-1.51) (0.35-1.06) (0.21-1.58)

Baseline ALT 0.0635

Mean 0.462 0.597 0.433 0.376

Median 0.365 0.458 0.396 0.333

Range (0.19-2.83) (0.05-2.73) (0.17-0.92) (0.06-1.00)

Baseline AST 0.3314

Mean 0.568 0.643 0.510 0.496

Median 0.491 0.548 0.500 0.476

Range (0.22-3.57) (0.12-2.29) (0.36-0.81) (0.21-1.19)

Baseline BILI 0.8190

Mean 0.385 0.427 0.429 0.415

Median 0.364 0.364 0.364 0.364

Range (0.14-1.05) (0.18-1.36) (0.23-1.00) (0.14-1.64)

p value is for Wilcoxon Rank Sum test for continuous measures and chi-square for all other variables comparing strict ALT cases and controls.

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Table 4: Strictly defined ALT >3 x ULN cases and controls and MHC genotypes among lapatinib-treated subjects

MHC Marker

Risk Genotype Categories

Cases Controls

Count % Count % OR (95% CI)

p-value

TNXB rs12153855

CC/CT genotype 17 11.6 130 88.4 5.23 (2.60-10.51)

8.4e-6


total 34 810

HLA-DRB1 *07:01


28 15.5 153 84.5 19.98 (8.13 – 49.10)

1.4e-14


total 34 808

HLA-DQA1 *02:01


28 15.5 153 84.5 19.95 (8.12 – 49.02)

1.5e-14


total 34 807

HLA-DQB1 *02:02


22 15.1 124 84.9 10.08 (4.86 – 20.90)

4.0e-10


total 34 806

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Table 5: Linkage disequilibrium among MHC genetic variants

TNXB rs12153855 HLA-DRB1*0701 HLA-DQA1*0201 HLA-DQB1*0202

TNXB rs12153855 1 0.65 0.65 0.48

HLA-DRB1*0701 0.74 1 0.99 0.86

HLA-DQA1*0201 0.75 0.99 1 0.85

HLA-DQB1*0202 0.51 0.98 0.98 1

Note: Correlation coefficient of risk-alleles above diagonal; D’ below the diagonal

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Table 6: Pairwise logistic regression of each MHC genetic variant adjusted for another MHC genetic variant for strictly defined ALT >3xULN cases and controls

Adjusting MHC Marker TNXB rs12153855 DRB1 *07:01 DQA1 *02:01 DQB1 *02:02 MHC Marker OR (95% CI) p-

value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value

TNXB rs12153855 X 0.8 (0.3, 1.7) 0.5227 0.8 (0.3, 1.7) 0.5226 1.7 (0.7, 4.0) 0.2192 DRB1 *07:01 23.3 (8.5, 64.3) 1.1e-9 X Undefined(1) 22.5 (6.9, 74.1) 2.8e-7 DQA1 *02:01 23.3 (8.5, 64.2) 1.1e-9 Undefined(1) X 22.6 (6.9, 74.2) 2.8e-7 DQB1 *02:02 7.6 (3.2, 18.0) 4.3e-6 0.9 (0.3, 2.3) 0.7696 0.9 (0.3, 2.3) 0.7696 X

(1)Undefined because DRB1*07:01 and DQA1*02:01 are so highly correlated that both cannot be fit at the same time in logistic regression

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Table 7: Performance metrics for MHC genetic variants and broadly defined cases and non-cases among lapatinib-treated subjects

MHC Marker Cases Non-Cases

OR (95% CI†) Sensitivity (95% CI‡)

Positive Predictive Value (95% CI‡)

Specificity (95% CI‡) Negative Predictive Value (95% CI‡)

TNXB rs12153855 ALT >3xULN 37 1069 4.68 (2.41, 9.09) 48.6 (31.9, 65.6) 9.1 (5.5, 14.0) 83.2 (80.8, 85.4) 97.9 (96.8, 98.7) ALT >5xULN 23 1083 3.66 (1.58, 8.48) 43.5 (23.2, 65.5) 5.1 (2.5, 9.1) 82.6 (80.3, 84.9) 98.6 (97.6, 99.2) ALT >10xULN 8 1098 7.82 (1.85, 32.98) 62.5 (24.5, 91.5) 2.5 (0.8, 5.8) 82.4 (80.0, 84.6) 99.7 (99.0, 99.9) HLA-DRB1 *07:01 ALT >3xULN 37 1067 14.12 (6.36, 31.32) 78.4 (61.8, 90.2) 11.7 (8.0, 16.4) 79.6 (77.0, 82.0) 99.1 (98.2, 99.6) ALT >5xULN 23 1081 17.77 (5.99, 52.75) 82.6 (61.2, 95.1) 7.7 (4.7, 11.8) 78.9 (76.4, 81.3) 99.5 (98.8, 99.9) ALT >10xULN 8 1096 †† 100.0 (63.1, 100.0) 3.2 (1.4, 6.3) 78.2 (75.6, 80.6) 100.0 (99.6, 100.0) HLA-DQA1 *02:01 ALT >3xULN 37 1065 14.08 (6.35, 31.24) 78.4 (61.8, 90.2) 11.7 (8.0, 16.4) 79.6 (77.0, 82.0) 99.1 (98.2, 99.6) ALT >5xULN 23 1079 17.73 (5.97, 52.63) 82.6 (61.2, 95.1) 7.7 (4.7, 11.8) 78.9 (76.3, 81.3) 99.5 (98.8, 99.9) ALT >10xULN 8 1094 †† 100.0 (63.1, 100.0) 3.2 (1.4, 6.3) 78.2 (75.6, 80.6) 100.0 (99.6, 100.0) HLA-DQB1 *02:02 ALT >3xULN 37 1064 8.64 (4.36, 17.13) 62.2 (44.8, 77.5) 11.9 (7.7, 17.3) 84.0 (81.7, 86.2) 98.5 (97.4, 99.2) ALT >5xULN 23 1078 7.81 (3.33, 18.33) 60.9 (38.5, 80.3) 7.3 (4.0, 11.9) 83.4 (81.0, 85.6) 99.0 (98.1, 99.6)

ALT >10xULN 8 1093 8.02 (1.90, 33.86) 62.5 (24.5, 91.5) 2.6 (0.9, 5.9) 82.8 (80.4,85.0) 99.7 (99.0, 99.9)

† Asymptotic confidence interval for the odds ratio (OR) ‡ Exact binomial confidence interval †† Note OR was not be computed because all cases were carriers of the variant

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Table 8: Lapatinib-treated Combined Cases: MHC Genotype and Liver Chemistry Summaries

Subject ID 3024 3532 3573 8743 10044 11277 9992 10410

*Concurrent visits defined as those where AST and/or ALT>3xULN and Total Bilirubin ≥2xULN

**Individual does not have MHC Genotype data available

30


This section contained data from each individual patient, rather than in aggregate. They have been excluded to protect patient privacy. Anonymized data from each patient may be made available subject to an approved research proposal. For further information please see the Patient Level Data section of the Sponsor Clinical Study Register.

Figure 1: Cumulative Incidence of ALT >3x in Strict Cases and Controls by MHC Genotype Carrier Status in the Lapatinib Arm

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Figure 2: Cumulative Incidence of ALT >3x in Strict Cases and Controls by MHC Genotype Carrier Status in the Placebo Arm

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Figure 3: Flow diagram of analysis populations for ALT >3X ULN

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UM2005/00179/07 CONFIDENTIAL The GlaxoSmithKline group of companies EGF105485

1

Division: Worldwide Development Retention Category: GRS019 Information Type: Protocol Amendment

Title: A Randomized, Double-blind, Multicenter, Placebo-controlled Study of Adjuvant Lapatinib in Women with Early-Stage ErbB2 Overexpressing Breast Cancer


Effective Date: 08-FEB-2011

Protocol Amendment Number: 07

Description: This is a randomized, double-blind, Phase III adjuvant study to evaluate and compare the safety and efficacy of single-agent lapatinib versus placebo in women with early-stage ErbB2-overexpressing breast cancer. Eligible women must have had an initial diagnosis of histologically or cytologically confirmed invasive breast cancer (Stage I through Stage IIIc) with ErbB2 overexpression defined as 3+ by immunohistochemisty (IHC) or c-erbB2 gene amplification by fluorescence in-situ hybridization (FISH). Eligible women must have completed primary neoadjuvant or adjuvant chemotherapy; however, those with hormone receptor-positive disease may remain on endocrine therapy during the study. Eligible women must have no clinical or radiographic evidence of disease at the time of study entry. The primary objective for this study is to evaluate and compare disease-free survival (DFS) in women treated with lapatinib versus placebo. Secondary objectives are to evaluate and compare between treatment arms the following: overall survival, recurrence-free intervals [local, regional, distant, and central nervous system (CNS)], rate of CNS recurrence, toxicity, and quality of life. Approximately 3000 women will be enrolled into this study.

Subject: GW572016, lapatinib, EGFR, ErbB1, HER-2/neu, ErbB2, dual kinase inhibitor, adjuvant breast cancer

Author: MD, PhD, Massachusetts General Hospital GlaxoSmithKline, Oncology Medicine Development Center (MDC):

MD; MD, PhD, RN, BSN; PhD PhD; PhD; Biostatistics &

Programming: MSc


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Revision Chronology:

UM2005/00179/00 2006-Apr-21 Original

UM2005/00179/01 2006-Sep-29 Amendment 01: Amendment of inclusion criterion #6 to clarify that all women must be considered for adjuvant trastuzumab treatment prior to enrollment in this study.

This amendment was requested by the French Comité de Protection des Personnes (CPP) and will apply only in France to coincide with the current treatment standard of trastuzumab in adjuvant breast cancer.

UM2005/00179/02 2007-Jan-31 Amendment 02: Addition of optional translation research objective to perform tumor tissue biopsy at the site of disease recurrence. Clarification of eligibility criteria, timing of study assessments and procedures, dose adjustments, and assessment of compliance. Modification of stopping boundaries for interim analysis.

UM2005/00179/03 2007-Jun-20 Amendment 03: A Companion Protocol was written to encompass the biomarker, proteomic, and pharmacogenetic research objectives for Study EGF105485 in accordance with Brazilian Regulations.

This amendment was required by Brazilian law and requested by the Comissao Nacional de Etica em Pesquisa (CONEP; National Comission for Ethics in Research). The Companion Protocol will apply only in Brazil to comply with Brazilian regulations and laws regarding genetic research.

UM2005/00179/04 2007-Jun-29 Amendment 04: A Sub-Study Protocol was written with the intention to characterize the effects of lapatinib on the corrected QT (QTc) interval in women with early-stage ErbB2-overexpressing breast cancer and to

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contribute to the comprehensive cardiac safety data for lapatinib.

This amendment was performed to address the ICH E14 (CHMP/ICH/2/04; effective from November 2005) guideline “The Clinical Evaluation of QT/QTc Interval Prolongation and Proarrhythmic Potential for Non-Antiarrhythmic Drugs”, which provides recommendations on how to assess the potential of a drug to delay cardiac repolarization as measured as prolongation of the QT interval on the surface ECG. A subset of women enrolled in the Core Protocol EGF105485 will participate in this sub-study, which will be conducted in selected investigative sites.

UM2005/00179/05 2008-May-21 Amendment 05: Increased frequency of standard chemistry testing to every 6 weeks. Addition of stopping rules and follow up criteria based on liver chemistry results. Widening of visit windows in the follow up phase of the study.

This amendment was performed following a review of all hepatobiliary events reported across the entire lapatinib clinical development programme. Based on the results of this review, GSK concluded a causal relationship between hepatobiliary disorders (specifically transaminase elevations) and lapatinib cannot be excluded.

UM2005/00179/06 2010-JAN-25 Amendment 06: Widening of visit windows in the follow up phase of the study.

UM2005/00179/07 2011-FEB-08 Amendment 07: Corrected Appendix 3 and 6 which were missing content. Updated Sponsor contact information.

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UM2005/00179/07 CONFIDENTIAL EGF105485

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Sponsor Signatory:

Signature: Date:

MD

Director, Oncology MDC

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SPONSOR INFORMATION PAGE

Clinical Study Identifier: EGF105485

Sponsor Contact Information:

GlaxoSmithKline 1250 South Collegeville Road Collegeville, PA 19426, USA Telephone Number:

GlaxoSmithKline 1-3 Iron Bridge Road Stockley Park West Uxbridge, Middlesex, UB11 1BT Telephone Number:

Regulatory Agency Identifying Number(s): Investigational New Drug (IND) Number: 61,362; European Drug Regulatory Authorities Clinical Trials (EudraCT) Number: 2005-005186-10

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INVESTIGATOR AGREEMENT PAGE

For protocol number 07

I confirm agreement to conduct the study in compliance with the protocol, as amended by this protocol amendment.

I acknowledge that I am responsible for overall study conduct. I agree to personally conduct or supervise the described clinical study.

I agree to ensure that all associates, colleagues and employees assisting in the conduct of the study are informed about their obligations. Mechanisms are in place to ensure that site staff receives the appropriate information throughout the study.

Investigator Name: _____________________________

Investigator Signature Date

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TABLE OF CONTENTS

PAGE

ABBREVIATIONS ........................................................................................................... 11

PROTOCOL SUMMARY ................................................................................................. 14

1. INTRODUCTION ..................................................................................................... 17 1.1. Background .................................................................................................. 17

1.1.1. Breast Cancer ............................................................................... 17 1.1.1.1. Role of ErbB Receptors in Breast Cancer ................... 17 1.1.1.2. Current Adjuvant Treatment of Breast Cancer ............ 18

1.1.2. Lapatinib ....................................................................................... 24 1.1.2.1. Preclinical .................................................................... 24

1.1.2.1.1. Theoretical Advantages of Dual Inhibition .................................................. 24

1.1.2.2. Clinical ......................................................................... 25 1.2. Rationale ...................................................................................................... 27

2. OBJECTIVES ........................................................................................................... 28 2.1. Primary Objective ......................................................................................... 28 2.2. Secondary Objectives .................................................................................. 28

2.2.1. Efficacy ......................................................................................... 28 2.2.2. Safety ............................................................................................ 28 2.2.3. Translational Research ................................................................. 29 2.2.4. Pharmacogenetic Research .......................................................... 29

3. ENDPOINT(S) .......................................................................................................... 29 3.1. Primary Endpoint .......................................................................................... 29 3.2. Secondary Endpoints ................................................................................... 30

3.2.1. Efficacy ......................................................................................... 30 3.2.2. Safety ............................................................................................ 30 3.2.3. Translational Research ................................................................. 30 3.2.4. Pharmacogenetic Research .......................................................... 31

4. STUDY DESIGN ...................................................................................................... 32

5. STUDY POPULATION ............................................................................................. 34 5.1. Number of Subjects ...................................................................................... 34 5.2. Eligibility Criteria ........................................................................................... 34

5.2.1. Inclusion Criteria ........................................................................... 34 5.2.2. Exclusion Criteria .......................................................................... 39 5.2.3. Other Eligibility Criteria Considerations ........................................ 40

6. STUDY ASSESSMENTS AND PROCEDURES ...................................................... 40 6.1. Demographic and Baseline Assessments .................................................... 40 6.2. Safety ........................................................................................................... 42

6.2.1. Laboratory Assessments .............................................................. 42 6.2.2. Pregnancy ..................................................................................... 43

6.2.2.1. Time period for collecting pregnancy information ................................................................... 44

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6.2.2.2. Action to be taken if pregnancy occurs ....................... 44 6.2.3. Cardiac Assessment ..................................................................... 44

6.2.3.1. Definitions and Cardiac Monitoring ............................. 45 6.2.3.1.1. Primary Cardiac Endpoints ..................... 45 6.2.3.1.2. Secondary Cardiac Endpoint .................. 45

6.2.3.2. Stopping and Holding Rules ........................................ 45 6.2.3.3. Treatment .................................................................... 46

6.3. Efficacy ......................................................................................................... 46 6.3.1. Clinical Outcome Assessment ...................................................... 46

6.3.1.1. Definitions and Diagnosis Criteria for Disease Recurrence and Second Primary Cancer .................... 47 6.3.1.1.1. Disease Recurrence ................................ 48 6.3.1.1.2. Second Primary Cancer .......................... 49

6.3.1.2. Dating of Disease Recurrence and Second Primary Cancer ........................................................... 49

6.4. Health Outcomes.......................................................................................... 50 6.5. Translational Research ................................................................................ 50

6.5.1. Tumor Tissue ................................................................................ 50 6.5.2. Plasma .......................................................................................... 51 6.5.3. Pharmacogenetic Research .......................................................... 51

7. INVESTIGATIONAL PRODUCT(S) ......................................................................... 52 7.1. Description of Investigational Product .......................................................... 52

7.1.1. Lapatinib ....................................................................................... 52 7.1.2. Placebo ......................................................................................... 52

7.2. Dosage and Administration .......................................................................... 52 7.2.1. Lapatinib or Placebo ..................................................................... 52 7.2.2. Dose Adjustments ......................................................................... 53

7.2.2.1. Criteria for Evaluating Asymptomatic or Mildly Symptomatic Cardiac Events ...................................... 55

7.2.2.2. Dose Delays ................................................................ 56 7.2.2.3. Dose Reductions ......................................................... 59

7.3. Dose Rationale ............................................................................................. 59 7.4. Blinding ........................................................................................................ 60 7.5. Treatment Assignment ................................................................................. 60

7.5.1. Stratification .................................................................................. 61 7.6. Packaging and Labeling ............................................................................... 61 7.7. Handling and Storage................................................................................... 61 7.8. Product Accountability .................................................................................. 62 7.9. Assessment of Compliance .......................................................................... 62 7.10. Treatment of Investigational Product Overdose ........................................... 63 7.11. Occupational Safety ..................................................................................... 63

8. CONCOMITANT MEDICATIONS AND NON-DRUG THERAPIES .......................... 63 8.1. Permitted Medications .................................................................................. 63 8.2. Prohibited Medications ................................................................................. 64 8.3. Non-Drug Therapies ..................................................................................... 65

9. SUBJECT COMPLETION AND WITHDRAWAL ...................................................... 66 9.1. Subject Completion ...................................................................................... 66 9.2. Subject Withdrawal....................................................................................... 66

9.2.1. Subject Withdrawal from Study ..................................................... 66

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9.2.2. Subject Withdrawal from Study Drug ............................................ 67 9.3. Treatment After the End of the Study ........................................................... 68 9.4. Extension Study ........................................................................................... 68 9.5. Screen and Baseline Failures ...................................................................... 68

10. ADVERSE EVENTS (AE) AND SERIOUS ADVERSE EVENTS (SAE) .................. 68 10.1. Definition of an AE........................................................................................ 69 10.2. Definition of a SAE ....................................................................................... 69

10.2.1. Disease-Related Events and/or Disease-Related Outcomes Not Qualifying as SAEs ............................................... 71

10.2.2. Clinical Laboratory Abnormalities and Other Abnormal Assessments as AEs and SAEs ................................................... 71

10.3. Lack of Efficacy ............................................................................................ 71 10.4. Time Period, and Frequency of Detecting AEs and SAEs ........................... 71 10.5. Prompt Reporting of SAEs to GSK ............................................................... 72 10.6. AE and SAE Documentation and Follow-up Procedures ............................. 73

11. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS ................................... 73 11.1. Hypotheses .................................................................................................. 73 11.2. Study Design Considerations ....................................................................... 73

11.2.1. Sample Size Assumptions ............................................................ 73 11.2.2. Sample Size Sensitivity ................................................................. 74 11.2.3. Sample Size Re-estimation ........................................................... 75

11.3. Data Analysis Considerations ...................................................................... 75 11.3.1. Analysis Populations ..................................................................... 75 11.3.2. Treatment Comparisons ............................................................... 75

11.3.2.1. Primary Comparisons of Interest ................................. 75 11.3.3. Interim Analysis ............................................................................. 75 11.3.4. Key Elements of Analysis Plan ..................................................... 76

11.3.4.1. Withdrawal ................................................................... 76 11.3.4.2. Missing Data ................................................................ 77 11.3.4.3. Derived and Transformed Data ................................... 77 11.3.4.4. Other Issues ................................................................ 77

11.3.5. Efficacy Analyses .......................................................................... 78 11.3.5.1. Primary Efficacy Analysis ............................................ 78 11.3.5.2. Secondary Analyses .................................................... 79

11.3.5.2.1. Percentages of Disease-Free Subjects: Time Point Estimates ............. 79

11.3.5.2.2. Overall survival ........................................ 79 11.3.5.2.3. Other Endpoints ...................................... 79

11.3.6. Safety Analyses ............................................................................ 80 11.3.6.1. Extent of Exposure ...................................................... 80 11.3.6.2. Adverse Events ........................................................... 80 11.3.6.3. Clinical Laboratory Evaluations ................................... 80 11.3.6.4. Other Safety Measures ............................................... 80

11.3.7. Health Outcomes Analyses ........................................................... 81 11.3.8. Biomarker(s) Analyses .................................................................. 82 11.3.9. Tumor Genetic Analyses ............................................................... 82

12. STUDY CONDUCT CONSIDERATIONS ................................................................. 83 12.1. Regulatory and Ethical Considerations, Including the Informed

Consent Process .......................................................................................... 83

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12.2. Quality Control (Study Monitoring) ............................................................... 83 12.3. Quality Assurance ........................................................................................ 84 12.4. Study and Site Closure................................................................................. 84 12.5. Records Retention........................................................................................ 85 12.6. Provision of Study Results and Information to Investigators ........................ 86 12.7. Information Disclosure and Inventions ......................................................... 86

12.7.1. Ownership ..................................................................................... 86 12.7.2. Confidentiality ............................................................................... 87 12.7.3. Publication .................................................................................... 87

12.8. Data Management ........................................................................................ 87 12.9. Independent Data Monitoring Committee ..................................................... 88

13. REFERENCES ........................................................................................................ 89

14. APPENDICES .......................................................................................................... 98 14.1. Appendix 1: Time & Events Table ............................................................... 99 14.2. Appendix 2: Pharmacogenetic Research .................................................. 102 14.3. Appendix 3: American Joint Committee on Cancer Staging Criteria ......... 109 14.4. Appendix 4: ECOG Performance Status Scale ......................................... 111 14.5. Appendix 5: Cockcroft and Gault Method for Calculated Creatinine

Clearance ................................................................................................... 112 14.6. Appendix 6: 36-Item Short Form (Version 2) Health Survey ..................... 113 14.7. Appendix 7: Country Specific Requirements ............................................. 119 14.8. Appendix 8: Protocol Changes .................................................................. 120

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ABBREVIATIONS

°C degrees centigrade AE adverse event Akt a protooncogene; also known as Protein Kinase B (PKB) ALP alkaline phosphatase ALT (SGPT) alanine aminotransferase ANCOVA analysis of covariance AST (SGOT) aspartate aminotransferase ASE American Society of Echocardiography ATAC Arimidex, Tamoxifen, Alone or in Combination ATP adenosine triphosphate β-hCG human chorionic gonadotrophin BID twice daily BT474 breast ductal carcinoma overexpressing ErbB2 cell line BUN blood urea nitrogen CHF congestive heart failure CNS central nervous system CT computed tomography CTCAE Common Terminology Criteria for Adverse Events CTEP Cancer Therapy Evaluation Program DCIS ductal carcinoma in situ DFS disease-free survival dL deciliter (100 mL) DNA deoxyribonucleic acid EBCTCG Early Breast Cancer Trialists’ Collaborative Group ECD extracellular domain (of protein receptors) ECG electrocardiogram ECOG Eastern Cooperative Oncology Group eCRF electronic case report form EGF epidermal growth factor EGFR epidermal growth factor receptor, also known as ErbB1 ER estrogen receptor ErbB1 EGFR; c-ErbB1; tyrosine kinase-type cell surface receptor HER1 ErbB2 c-ErbB2; also known as HER-2/neu; tyrosine kinase-type cell

surface receptor HER2 ErbB3 c-ErbB3, tyrosine kinase-type cell surface receptor HER3 ErbB4 c-ErbB4, tyrosine kinase-type cell surface receptor HER4 FISH fluorescence in situ hybridization g grams GCP good clinical practice GCSP Global Clinical Safety and Pharmacovigilance GSK GlaxoSmithKline HDPE high-density polyethylene HERA Herceptin Adjuvant trial IB Investigator's Brochure ICF informed consent form IDMC Independent Data Monitoring Committee

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IES Intergroup Exemestane Study IEC independent ethics committee IGF1R insulin-like growth factor-1 receptor IHC immunohistochemistry IND investigational new drug IRB institutional review board ITT Intent-to-treat IVR interactive voice response (system) kg kilograms L liter LCIS lobular carcinoma in situ LVEF left ventricular ejection fraction MAPK mitogen-activated protein kinase, also known as Erk1/2 MedDRA Medical Dictionary for Regulatory Activities mg milligram(s) MGH Massachusetts General Hospital min(s) minute(s) mL milliliter(s) MOS Medical Outcomes Study MRI magnetic resonance imaging MSDS Material Safety Data Sheet MUGA multigated acquisition NCCTG North Central Cancer Treatment Group NCI National Cancer Institute NONMEM non-linear mixed effects modeling NSABP National Surgical Adjuvant Breast and Bowel Project NYHA New York Heart Association PET positron emission tomography PgR progesterone receptor PGx pharmacogenetics PI3K phosphatidylinositol-3-kinase PP per protocol PR partial response PTEN phosphatase and tensin homolog p-Tyr phosphorylated tyrosine QD once daily QoL quality of life QT interval ventricular repolarization on surface ECG QTc interval corrected QT interval RAMOS Registration And Medication Ordering System RAP Reporting and Analysis Plan RNA ribonucleic acid SAE serious adverse event SF-36 36-item short-form SNP single nucleotide polymorphism SRM Study Reference Manual TGF-α tumor growth factor - alpha TK tyrosine kinase

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ULN upper limit of normal US United States VEGF vascular endothelial growth factor

Trademark Information



None Herceptin NONMEM

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PROTOCOL SUMMARY

Rationale

Preliminary results from two US-based adjuvant trials and a global adjuvant trial in women with high-risk ErbB2-overexpressing breast cancer have shown that the addition of trastuzumab (Herceptin), a humanized ErbB2 (HER-2/neu) directed monoclonal antibody, to standard adjuvant chemotherapy significantly reduced the risk of disease recurrence by 52% (hazard ratio = 0.48; 95% CI: 0.39 to 0.59) [Romond, 2005] and 46% (hazard ratio = 0.54; 95% CI: 0.43 to 0.67) [Piccart-Gebhart, 2005]. Based on these encouraging data, trastuzumab has become part of standard therapy in the adjuvant setting together with chemotherapy. However, many thousands of women with ErbB2-overexpressing breast cancer have already received adjuvant chemotherapy without the addition of trastuzumab. Currently, no data are available to support the use of trastuzumab as treatment for women who have already completed their adjuvant chemotherapy. However, as evidenced by the recurrence rate of breast cancer in women treated without trastuzumab in the aforementioned trials, these women have a high risk of disease recurrence. Thus, an unmet clinical need exists in the treatment of women with ErbB2-overexpressing breast cancer who previously received adjuvant chemotherapy without trastuzumab.

Between 20% and 40% of human breast cancers overexpress the HER2 protein [Slamon, 1987; Slamon, 1989]. Because of the distinctive clinical features of HER2-positive breast cancer, women have a higher risk of recurrence and thus, poorer prognosis compared with those with HER2-negative disease [Burstein, 2005]. The aforementioned results observed with trastuzumab indicate that a single ErbB2 inhibitor had activity as adjuvant treatment of ErbB2-positive breast cancer. Lapatinib is a reversible tyrosine kinase inhibitor that potently inhibits both ErbB1 and ErbB2 tyrosine kinase activity. In preclinical studies, lapatinib inhibited tumor growth in ErbB2-overexpressing breast ductal carcinoma cell lines. Furthermore, data suggest that a dual ErbB1 and ErbB2 inhibitor may provide improved therapeutic benefit compared with inhibitors that target

either receptor alone [Rusnak, 2001]. In the clinical setting, single-agent lapatinib has been shown to be safe, and preliminary Phase II data have shown promising activity of lapatinib as treatment of metastatic breast cancer [Stein, 2005].

To address the above-mentioned unmet clinical need, the current study (EGF105485) will establish whether adjuvant treatment with oral single-agent lapatinib in women with early-stage ErbB2-overexpressing breast cancer will improve disease-free survival. This study is designed to compare the efficacy and safety of lapatinib versus placebo in women who have no clinical or radiographic evidence of disease and have not been previously treated with trastuzumab.

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Objective(s)

Primary Objective

The primary objective is to determine whether adjuvant therapy with lapatinib will improve disease-free survival in women with early-stage ErbB2-overexpressing breast cancer.

Secondary Objectives

The secondary objectives are to evaluate and compare between treatment arms the following: overall survival; recurrence-free intervals [local, regional, distant, and central nervous system (CNS)]; the rate of CNS recurrence; toxicities; and quality of life, as physical and mental health status.

In addition, a specific sub-study evaluating the effect of lapatinib on QT/QTc interval will be conducted in selected centers in a subset of subjects. A separate companion protocol has been written to encompass this study.

Exploratory Objectives

The study will assess relevant biomarkers and genetic changes in plasma and intra-tumoral samples and their correlation to both drug efficacy and clinical outcome. The pharmacogenetic objective of the study is to investigate the relationship between genetic variants in candidate genes in the host and response (efficacy, safety and tolerability) to lapatinib.

In addition, an analysis comparing the transcriptional and protein profile of the archived tumor tissue sample to that of a tumor biopsy sample obtained at the time of disease recurrence will be conducted.

Study Design

Study EGF105485 is a randomized, double-blind, placebo-controlled, adjuvant Phase III study comparing the efficacy and safety of lapatinib versus placebo in women with early-stage ErbB2-overexpressing breast cancer. Approximately 3000 women will be enrolled and randomly assigned in a 1:1 fashion to receive either lapatinib or placebo. Women will be stratified by time from initial diagnosis, lymph node involvement, and hormone receptor status.

Lapatinib 1500mg or matching placebo will be administered orally once daily. Women will continue treatment for a maximum of 1 year or stop earlier because of disease recurrence, withdrawal from study treatment due to unacceptable toxicity, or consent withdrawal. All women will be followed until death or study closure.

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Study Population

The study will be conducted in women with early-stage ErbB2–overexpressing breast cancer. Women will have histologically or cytologically confirmed invasive breast cancer with lymph node positive or intermediate- or high-risk lymph node negative disease. Women must have no clinical or radiographic evidence of disease at the time of study entry. Women must have completed primary neoadjuvant or adjuvant chemotherapy prior to study enrollment, but prior treatment with trastuzumab is not allowed; women who experienced a hypersensitivity or allergic reaction to trastuzumab during the first infusion and were unable to complete this infusion are eligible.

Study Assessments

Safety and tolerability will be evaluated by adverse event/toxicity assessment, laboratory tests, including standard hematology and chemistry panels, and cardiac evaluations, including 12-lead electrocardiogram and echocardiogram or multigated acquisition. Adverse events will be assessed using the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (Version 3.0) [National Cancer Institute, 2005]. Assessments will be performed every 3 months while on study therapy.

Efficacy will be evaluated through clinical assessment (medical history, physical examination, and evaluation of other signs and symptoms that may be suggestive of disease recurrence or a second primary cancer). Radiological imaging (chest x-ray, CT scan, or MRI, bone scan, and/or head MRI, if applicable) and histological and/or cytological biopsies (if applicable) will be performed when symptoms suggest disease recurrence or a second primary cancer and at the discretion of the investigator. Clinical assessments will be performed every 3 months while on study therapy, with the exception of standard chemisty which will be performed every 6 weeks or more frequently if clinically indicated while on study therapy to monitor liver function.

Health-related quality of life will be assessed through use of a general health status questionnaire, the Medical Outcomes Study 36-item Short-Form (Version 2), acute recall instrument developed by the Medical Outcomes Trust [Ware, 1992; McHorney, 1993; Ware, 2001]. Eight sub-scale values and two summary measures of physical and mental components of health will be scored. During the study treatment period, the SF-36v2 will be completed every 6 months (i.e., at Month 6 and Month 12). After withdrawal from study drug, the SF-36v2 will be completed every 6 months for 24 months.

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1. INTRODUCTION

1.1. Background

1.1.1. Breast Cancer

Globally, breast cancer is the most common malignancy reported annually among women [Parkin, 2005]. Worldwide, breast cancer ranks as the fifth cause of death from cancer overall, although still the primary cause of cancer mortality in women. In the United States (US), breast cancer is the second cause of cancer-related death after lung cancer and the primary cause of cancer-related deaths in women aged 45 to 55 [Jemal, 2005]. The worldwide incidence of breast cancer in the year 2002 was estimated at 1.15 million new cases; mortality in the same year was estimated at 411,000 deaths [Parkin, 2005]. In the US, an estimated 211,240 women will be diagnosed with breast cancer in 2005 and 40,410 will die of their disease [Jemal, 2005].

1.1.1.1. Role of ErbB Receptors in Breast Cancer

Breast cancer is a heterogeneous disease, notably in terms of response to therapy and varied natural histories. With the use of comprehensive gene expression profiles defined by deoxyribonucleic acid (DNA) microarray analysis [Ramaswamy, 2002], the classification of breast cancer tumors has been divided into 5 distinct clinical subtypes [Sorlie, 2001]. One of these unique subtypes overexpresses HER2 on the surface of breast tumor cells caused by amplification of the HER2/neu oncogene [Sorlie, 2001; Sorlie, 2003; Burstein, 2005]. The HER2/neu gene is one of four members of a family of genes encoding transmembrane receptors for growth factors. The other three are ErbB1 [also known as the epidermal growth factor receptor (EGFR) or HER1], ErbB3 (HER3), and ErbB4 (HER4). The four members of this family share a similar conserved structure––an extracellular ligand-binding domain, a single transmembrane-spanning domain, and an intracellular tyrosine kinase domain.

Upon binding of ligands, ErbB receptors become activated and undergo hetero- or homodimerization. Ligand-mediated dimerization of the ErbB receptors and subsequent autophosphorylation or transphosphorylation leads to their association with a variety of cytoplasmic phosphotyrosine binding proteins. This results in the initiation of a phosphorylation cascade and activation of several downstream pathways involved in cell growth [mitogen-activated protein kinase (MAPK); also known as Erk1/2] and survival [phosphatidylinositol-3-kinase (PI3K/Akt)] [Yarden, 2001]. Stimulation of these pathways transmits a signal to the nucleus resulting in modification of gene transcription patterns that ultimately affects processes, such as cell division, apoptosis, adhesion, migration, and/or differentiation. No ligand has yet been identified for ErbB2 suggesting its primary role is to modulate signals after ligand binding to other ErbB-family receptors [Burstein, 2005].

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Between 20% and 40% of human breast cancers overexpress the HER2 protein [Slamon, 1987; Slamon, 1989]. The clinical relevance of HER2 expression became evident when patients with HER2-positive breast cancer demonstrated a worse prognosis than those with HER2-negative tumors. Overexpression of HER2 appears to be associated with poorly differentiated, high-grade tumors, increased rates of cell proliferation and lymph node involvement, and a relative resistance to certain types of chemotherapy [Burstein, 2005]. Although several studies have demonstrated that patients with HER2-positive breast cancer have a relative resistance to endocrine therapy in the adjuvant setting [Carlomagno, 1996; De Placido, 2003], data from other clinical studies have shown either a positive effect or no effect of HER2 status on response to endocrine therapy [Love, 2003; Knoop, 2001; Berry, 2000]. Similarly, conflicting results have been noted on the relationship between overexpression of HER2 and response to adjuvant therapy with cyclophosphamide, methotrexate, and fluorouracil [Allred, 1992; Gusteron, 1992; Menard, 2001]. These distinctive clinical features contribute to higher risk of recurrence and thus, poorer prognosis seen among women with HER2-positive breast cancer. Given that expression of HER2 is a poor prognostic factor for breast cancer, many therapeutic strategies have been employed to block HER2 signaling pathways.

1.1.1.2. Current Adjuvant Treatment of Breast Cancer

Treatment of early-stage breast cancer usually consists of a combination of surgery, radiotherapy, and adjuvant systemic therapies, such as chemotherapy, and biological and hormonal agents [Winer, 2001]. The final results from the worldwide meta-analysis coordinated by the Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) showed that anthracycline-based adjuvant regimens reduce the risk of 15-year recurrence and mortality rates [Early Breast Cancer Trialists’ Collaborative Group, 2005]. In addition, adjuvant tamoxifen was shown to substantially improve 15-year survival rates in women with estrogen receptor- (ER) positive breast cancer. These findings suggest that some of the adjuvant regimens which emerged over the past two decades and yielded reductions in 5-year recurrence rates have also shown substantial benefit in reducing mortality rates at 15 years.

More recently, two large randomized trials demonstrated that the addition (sequential or concurrent) of a taxane (paclitaxel or docetaxel) to a standard anthracycline-based adjuvant regimen improved the disease-free survival (DFS) and overall survival times of patients with operable node-positive breast cancer [Henderson, 2003; Martin, 2005].

Additionally, studies have indicated an improvement in DFS and recurrence-free survival with the use of aromatase inhibitors in postmenopausal women with hormone receptor-positive breast cancer. The results of these studies are listed in Table 1.

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Table 1 Results of Phase III Studies of Aromatase Inhibitors as Adjuvant Treatment of Hormone Receptor-Positive Breast Cancer

ATAC Trial MA.17 Trial IES Trial BIG 1-98

Tam (N=2598)

Anastrozole

(N=2618)

Tam f/b Placebo (N=2587)

Tam f/b Letrozole (N=2583)

Tam

(N=2380)

Tam f/b Exemestane1

(N=2362)

Tam

(N=4007)

Letrozole (N=4003)

Disease-free survival Events, n 6512 5752 1553 923 2662 1832 4284 3514 HR (95% CI) p value

0.87 (0.78 to 0.97); 0.01

0.58 (0.45 to 0.76); <0.001

0.68 (0.56 to 0.82); 0.00005

0.81 (0.70 to 0.93) p=0.003

Recurrence-free survival Events, n 4985 4025 826 526 2275 1445 3107 2287 HR (95% CI) p value

0.79 (0.70 to 0.90); 0.0005

0.60 (0.43 to 0.84); 0.002

0.63 (0.51 to 0.77); 0.00001

0.72 (0.61 to 0.86); p<0.001

1. women switched to exemestane after 2 to 3 years of tamoxifen therapy. 2. included local or distant recurrence, second primary breast cancer, and death from any cause 3. included local, regional or distant recurrence and second primary breast cancer 4. included local, regional, or distant recurrence, contralateral breast cancer, any second primary non-breast cancer, and death without prior cancer event 5. included local or distant recurrence and second primary breast cancer (censoring death from any cause before recurrence) 6. included distant recurrence only 7. included local, regional, or distant recurrence, contralateral breast cancer (censoring death from any cause before recurrence) Abbreviations: ATAC = Arimidex, Tamoxifen, Alone or in Combination; CI = confidence interval; f/b = followed by; HR = hazard ratio; IES = Intergroup Exemestane Study; N = number of patients; n = number of patients with event; Tam = tamoxifen. Data source: [Coombes, 2004; ATAC Trialist Group, 2005; Goss, 2005; The Breast International Group (BIG) 1-98 Collaborative Group, 2005]

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Further understanding of the heterogeneity of breast cancer tumors has prompted the development of individualized therapies in breast cancer. Following the discovery that amplification of the HER-2/neu gene in breast cancer contributes to poor prognosis, a novel antibody that targets the overabundant HER2 protein was developed. Preliminary results from several adjuvant studies of trastuzumab (Herceptin), a humanized ErbB2 (HER-2/neu) directed monoclonal antibody, were recently published. The combined data of a first interim analysis of two US-based studies, the North Central Cancer Treatment Group (NCCTG) Intergroup study N9831 and the National Surgical Adjuvant Breast and Bowel Project (NSABP) study B-31, and the interim analysis of the global Herceptin Adjuvant (HERA) trial showed promising clinical benefits of trastuzumab when administered either sequentially or concurrently with adjuvant chemotherapy [Romond, 2005; Piccart-Gebhart, 2005]. In addition, preliminary results of two adjuvant studies of trastuzumab administered concurrently with chemotherapy were recently presented at the 28th Annual San Antonio Breast Cancer Symposium 2005 [Slamon, 2005; Joensuu, 2005]. The analyses of the studies, the Breast Cancer International Research Group 006 study and the FinHer Trial, showed a magnitude of benefit with the addition of trastuzumab similar to that observed in the aforementioned adjuvant studies. The results of the efficacy analyses of these studies are listed in Table 2.

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Table 2 Interim Efficacy Results of Phase III Studies of Trastuzumab as Adjuvant Treatment of HER2-Positive Breast Cancer

Disease-Free Survival Overall Survival Study Treatment Arm (N)

Median f/u

(years)

Events

(n)

HR (95% CI); p value

Events

(n)

HR (95% CI); p value

Combined Analysis

AC→TH (1672) 2

1331

0.48 (0.39 to 0.59);

62

0.67 (0.48 to 0.93);

AC→T (1679) 2611 p<0.0001 92 p=0.015 NSABP-B31 AC→TH (864) 2.4 831 0.45; n/a n/a AC→T (872) 1711 p=1×10-9 n/a n/a NCCTG N9831 AC→TH (808) 1.5 511 0.55; n/a n/a AC→T (807) 901 p=0.0005 n/a n/a HERA Trial 1° therapy2→H3 (1694)

1

1274

0.54

29

0.76

1° therapy2→obs (1693)

2204

(0.43-0.67); p<0.0001

37

(0.47 to 1.23); p=0.26

BCIRG 006 study AC→DH (1074)

1.9

775 0.496

(0.37 to 0.65); p<0.0001

20

n/a

DCbH (1075) 985

0.617 (0.47 to 0.79);

p=0.0002

28

n/a

AC→D (1073) 1475 36 n/a FinHer Trial8 DH / VinH→FEC (115)

3.2

119

0.46 (0.21 to 0.83)

6

0.41 (0.16 to 1.08)

D or Vin →FEC (116)

269 p=0.01 14 p=0.07

continued

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Table 2 Interim Efficacy Results of Phase III Studies of Trastuzumab as Adjuvant Treatment of HER2-Positive Breast Cancer

1. included local, regional, and distant recurrence; contralateral breast cancer, including DCIS; other second primary cancers; and death before recurrence or a second primary cancer.

2. may have included surgery and adjuvant and neoadjuvant or both, with or without radiotherapy. 3. random assignment to trastuzumab for 1 year occurred within 7 weeks from Day 1 of the last chemotherapy cycle,

or 6 weeks from the end of radiotherapy or definitive surgery, whichever was last. 4. included recurrence of breast cancer at any site; ipsilateral or contralateral breast cancer, including DCIS but not

LCIS; second nonbreast malignant disease other than basal cell or squamous cell carcinoma of the skin or carcinoma in situ of the cervix; or death from any cause without documentation of a cancer-related event

5. included breast cancer recurrence, second primary cancer, and death. 6. for the comparison of AC →DH vs AC →D. 7. for the comparison of DCbH vs AC →D. 8. data presented are from a subset of patients with ErbB2 amplification by CISH who were randomized to either a 9

weekly cycle of trastuzumab concurrent with either docetaxel or vinorelbine or no trastuzumab. 9. included local, distant or contralateral invasive breast cancer or death. Abbreviations: AC = anthracycline + cyclophosphamide; BCIRG = Breast Cancer International Research Group; CI = confidence interval; CISH = chromogen in situ hydridization; DCIS = ductal carcinoma in situ; D = docetaxel; DH = docetaxel + trastuzumab; DCbH = docetaxel + carboplatin + trastuzumab; FEC = 5-fluorouracil + epirubicin, + cyclophosphamide; f/u = follow up; H = trastuzumab; HERA = Herceptin Adjuvant; HR = hazard ratio; LCIS = lobular carcinoma in situ; N = number of patients; n = number of patients with events; n/a = not available; NCCTG = North Central Cancer Treatment Group; NSABP = National Surgical Adjuvant Breast and Bowel Project; T = paclitaxel; TH = paclitaxel + trastuzumab; Vin = vinorelbine; VinH= vinorelbine + trastuzumab. Data Source: [Romond, 2005; Piccart-Gebhart, 2005; Slamon, 2005; Joensuu, 2005] Given the increased risk of cardiac dysfunction associated with trastuzumab administered in patients previously treated with or concurrently receiving anthracyclines, cardiac function was closely assessed in all studies. During the 3-year follow-up period of the FinHer Trial, left ventricular ejection fractions (LVEF) were maintained among patients receiving trastuzumab [Joensuu, 2005]. The safety data pertaining to cardiac events from the other adjuvant trastuzumab studies (NSABP B-31, NCCTG N9831, the HERA trial, and BCIRG 006 study) are presented in Table 3.

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Table 3 Interim Cardiac Safety Results of Phase III Studies of Trastuzumab as Adjuvant Treatment of HER2-Positive Breast Cancer

Study Protocol-Specified Cardiac Event Treatment Arm (N) n (%) p value NSABP-B31 AC→TH (850) 31 (4.1)1,2 n/a AC→T (814) 5 (0.8)1,2 n/a NCCTG N9831 AC→TH 21 (2.9)1 n/a AC→T 0 n/a HERA Trial 1° therapy→H (1677) 29 (1.73)3 p<0.001 1° therapy→obs (1710) 1 (0.06)3 BCIRG 006 study AC→DH (1068) 25 (2.34)4 p=0.016 (AC→DH vs AC→D) DCbH (1056) 14 (1.33)4 p=0.54 (DCbH vs AC→D) AC→D (1050) 10 (0.95)4 1. defined as confirmed NYHA class III and IV CHF or possible/probable cardiac death. 2. data reported are the estimated 3-year cumulative incidence rate of cardiac events; the relative risk of cardiac

event was 5.9 (95% CI 2.3 to 15.3); p<0.0001. 3. defined as CHF considered symptomatic by a cardiologist, and a ≥10% decrease in LVEF from baseline to an

LVEF <50% at any time; does not include cardiac-related deaths, but includes severe CHF (defined as NYHA class III or IV, as confirmed by a cardiologist, and a ≥10% decrease in LVEF from baseline to an LVEF <50% at any time).

4. defined as cardiac-related death, Grade 3/4 left ventricular cardiac function (CHF), Grade 3/4 cardiac ischemia/infarction, or Grade 3/4 arrhythmias; data reported are from independent review panel.

Abbreviations: AC = anthracycline + cyclophosphamide; BCIRG = Breast Cancer International Research Group; D = docetaxel; DH = docetaxel + trastuzumab; DCbH = docetaxel + carboplatin + trastuzumab; H = trastuzumab; HERA = Herceptin Adjuvant; N = number of patients; n = number of patients with events; n/a = not available; NCCTG = North Central Cancer Treatment Group; NSABP = National Surgical Adjuvant Breast and Bowel Project; T = paclitaxel; TH = paclitaxel + trastuzumab. Data Source: [Romond, 2005; Piccart-Gebhart, 2005; Slamon, 2005; Tan-Chui, 2005] Adjuvant therapies, such as anthracycline-based chemotherapy regimens and tamoxifen, have demonstrated improvement in long-term outcome, and more recently, agents, such as taxanes, aromatase inhibitors, and an ErbB2 inhibitor, have demonstrated improvement in short-term outcome. However, women treated for early-stage breast cancer remain at risk of development of a life-threatening recurrence of disease. Although this risk is greater within the first three years after adjuvant therapy [Jato, 2005], the risk of recurrence still exists up to 30 years after initial diagnosis [Rosen, 1989; Rutqvist, 1984]. In fact, the recent EBCTCG meta-analysis showed that the overall 15-year probability of disease recurrence was 53.4% among women aged 50 to 69 years who received adjuvant polychemotherapy. Studies assessing the impact of ErbB2 status on long-term outcome have shown better DFS and overall survival times among patients with ErbB2-negative tumors compared with Erb2-overexpressing cancers [Carlomagno, 1996; De Placido, 2003; Menard, 2001]. Since trastuzumab has become part of the standard adjuvant treatment for women with early-stage HER2-positive breast

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cancer, other agents for women, who did not or cannot for practical reasons receive treatment with trastuzumab, will need to be explored.

1.1.2. Lapatinib

1.1.2.1. Preclinical

Lapatinib is an orally active, reversible small-molecule dual kinase inhibitor targeting both ErbB1 and ErbB2 receptors. It works inside the cell and directly targets the tyrosine kinase (TK) domain. Lapatinib reversibly binds to the cytoplasmic adenosine triphosphate- (ATP) binding site of the kinase and blocks receptor phosphorylation and activation, thereby preventing subsequent downstream signalling events (simultaneous activation of Erk1/2 and P13K/Akt).

In vitro studies assessing the specificity of lapatinib by examining effects on 18 various proteins demonstrated that lapatinib was >1000-fold more potent towards ErbB1 or ErbB2 than any other enzymes. Studies on ErbB2-overexpressing breast ductal carcinoma cell lines (BT474) showed that lapatinib dramatically inhibited the phosphorylation of ErbB1 and ErbB2, and of Akt in a dose-responsive manner. In a mouse subcutaneous BT474 xenograft model, lapatinib inhibited tumor growth by 94%; tumor regression of >25% was also observed. In ErbB2 phosphorylated tyrosine (p-Tyr) status assays, lapatinib reduced ErbB2 p-Tyr in mice by 93% following a total of 5 doses at 100 mg/kg twice a day. The association between ErbB1/ErbB2 expression and lapatinib effects in breast cancer cell lines suggests that the compound is selectively and preferentially inhibiting its intended target.

1.1.2.1.1. Theoretical Advantages of Dual Inhibition

There are several theoretical advantages of an inhibitor of both ErbB1 and ErbB2 compared with inhibitors of either one of these TKs alone. While small molecule inhibitors of ErbB1 can block signaling through ErbB1 homodimers, these agents may not be as effective at inhibiting heterodimers containing both ErbB1 and ErbB2. In addition to ErbB:ErbB heterodimers, other growth factor receptors have been shown to form heterodimers with ErbB receptors, notably, insulin-like growth factor receptor 1 (IGFR-1), which forms heterodimers with both ErbB1 and ErbB2. In this regard, co-expression of IGFR-1 with ErbB2 overexpression has been shown to mediate resistance to trastuzumab in preclinical models and in patients [Lu, 2001; Bacus , 2004]. However, the presence of IGFR-1 and ErbB2 overexpression appears to predict for sensitivity of breast cancer cells to the anti-tumor effects of lapatinib [Spector, 2005; Gomez, 2005]. This suggests that in tumor cells expressing multiple ErbB family members as well as other growth factor receptors (e.g., IGFR-1), incomplete blockade of ErbB1 and ErbB2 receptor signalling may still enable growth and/or survival signals to be transmitted.

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A potential limitation of antibody-directed ErbB2 therapy is the occurrence in tumors of truncated forms of both ErbB1 and ErbB2, which are not recognized by antibodies to the external domains of these proteins. A truncated form of ErbB2, termed p95, has increased kinase activity compared with wild-type ErbB2. Expression of p95 in breast cancers has been shown to correlate with lymph node metastasis in patients with ErbB2-overexpressing tumors. Preclinical studies have shown lapatinib inhibits baseline p95ErbB2 phosphorylation in BT474 cells and tumor xenografts. Whereas, trastuzumab neither binds to nor inhibits p95, suggesting that trastuzumab resistance may be mediated through increased expression of the p95ErbB2 during disease progression [Xia, 2004]. A similar phenomenon was observed when a soluble vascular endothelial growth factor (VEGF) receptor-1 immunoglobulin-γ chimeric protein failed to induce hematopoietic stem cell apoptosis suggesting that the mechanism of VEGF may be refractory to inhibitors, such as antibodies, that fail to penetrate the intracellular domain and act only in the extracellular domain [Gerber, 2002].

Some studies have shown that increased expression of epidermal growth factor (EGF) or transforming growth factor α (TGF-α), which are ligands for ErbB1, is a poor prognostic factor [Albanell, 2001; Grandis, 1998]. Expression of these ligands appears to be responsible for maintaining ErbB receptors in an activated state even in the absence of receptor overexpression [Albanell, 2001; Howell, 1998; Jiang, 1998]. Lapatinib exhibited greater growth inhibition of TGF-α-activated cancer cells compared with antagonists targeting only ErbB1 or ErbB2 receptors [Zhou, 2003].

These data suggest that a dual ErbB1 and ErbB2 inhibitor may provide improved therapeutic benefit as compared with inhibitors that target either receptor alone [Rusnak, 2001].

1.1.2.2. Clinical

The efficacy and safety of lapatinib as a single agent are currently being assessed in several clinical Phase II studies of metastatic breast cancer.

Promising early clinical activity with lapatinib has recently been reported for patients with locally advanced or metastatic breast cancers that exhibit ErbB2 gene amplification by fluorescence in situ hybridization (FISH) [Stein, 2005]. In this open-label, randomized, two-arm study (EGF20009) of lapatinib 1500mg once daily (QD) or 500mg twice daily (BID) as first-line treatment, an interim analysis by independent radiology review was performed in 40 patients followed for a minimum of 12 weeks. Results included a partial response (PR) in 14 (35%) patients, an unconfirmed PR in 2 (5%) patients, stable disease in 14 (35%) patients, and progressive disease or unknown efficacy in 5 (12.5%) patients each. These data are similar to those of trastuzumab monotherapy reported in a similar patient population (34% response rate in a FISH-positive subgroup) [Vogel, 2002]. No Grade 3 or 4 events assessed using the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) were reported thus far.

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Lapatinib is also being studied in patients with breast cancer with brain metastasis. Preliminary evidence of biological and clinical activity of lapatinib has been observed in an ongoing Phase II Cancer Therapy Evaluation Program- (CTEP) sponsored study (Trial 6969; personal communication, and As of October 2005, Trial 6969 has completed enrollment for a total of 39 subjects, of which 17 subjects remain on study. The safety profile of lapatinib in this patient population appears to be similar to that seen in other monotherapy lapatinib breast cancer trials. Another Phase II study (EGF105084) will evaluate the clinical activity of lapatinib in subjects with progressive, symptomatic or asymptomatic ErbB2-overexpressing breast cancer brain metastases following trastuzumab-based systemic therapy and cranial radiotherapy.

Patients with ErbB2-overexpressing breast cancer appear to be at high risk for the development of visceral metastases, including the brain [Grossi, 2003; Pestalozzi, 2000]. The increased incidence of brain metastasis is likely a reflection of both the inherent behavior of HER-2/neu-positive tumors, as well as the prolonged survival in these patients, which has allowed more central nervous system (CNS) metastases to become clinically evident before death. Therefore, small molecule TK inhibitors that target ErbB2-overexpressing tumors and have the potential to cross the blood-brain barrier could yield positive activity in brain metastases. Although trastuzumab-based regimens have improved both systemic control and overall survival in patients with ErbB2-overexpressing metastatic breast cancer [Cobleigh, 1999; Slamon, 2001; Vogel, 2002; Burstein, 2001], trastuzumab does not cross the blood-brain barrier. Retrospective analyses revealed a 28% to 43% incidence of CNS metastases among women treated with trastuzumab for Stage IV ErbB2-overexpressing breast cancer [Wardley, 2002; Weitzen, 2002; Heinrich, 2003; Bendell, 2003; Clayton, 2004]. Thus, CNS metastasis is emerging as a major clinical problem in this patient population.

On the basis of preliminary results from clinical trials of lapatinib, continued development of lapatinib for metastatic breast cancer and exploration of lapatinib as adjuvant therapy for early-stage breast cancer is warranted. Furthermore, since lapatinib potentially crosses the blood-brain barrier and has demonstrated activity in the brain, investigation of whether a clinical benefit, in terms of decreasing the rate of CNS metastases, can be derived from treatment with lapatinib is warranted.

Further details about the known benefits and risks of lapatinib may be found in the Investigator’s Brochure (IB).

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1.2. Rationale

Trastuzumab will likely become part of standard therapy in the adjuvant setting together with chemotherapy. However, many thousands of women with ErbB2-overexpressing breast cancer have received adjuvant chemotherapy without the addition of trastuzumab because these data were unavailable at the time of diagnosis and treatment. Currently, no data are available to support the use of trastuzumab as treatment for these women. The clinical outcome of patients with ErbB2-positive breast cancer has not been well defined; however, overexpression of ErbB2 is a consistently documented poor prognostic factor in breast cancer. As evidenced by the recurrence rate in women not treated with trastuzumab in the aforementioned adjuvant trials, these women have a high risk of disease recurrence. Thus, an unmet clinical need exists in the treatment of women who previously received adjuvant chemotherapy without trastuzumab.

The use of an ErbB inhibitor following the completion of standard adjuvant therapy represents an intriguing new concept. Endocrine therapies, such as tamoxifen [Delozier, 2000] and aromatase inhibitors (refer to Table 1), have demonstrated improvements in DFS when therapy is initiated at times ranging from 2 to 6 years after standard adjuvant chemotherapy is completed. Patients with ErbB2-overexpressing breast cancer who are in remission but remain at high risk for recurrence following adjuvant systemic therapy may benefit from treatment with an ErbB inhibitor, especially if such treatment can be administered easily and without compromising safety and quality of life.

Lapatinib appears to be an ideal drug to study as single-agent therapy in women, who have ErbB2-overexpressing breast cancer and are in remission following adjuvant chemotherapy, for several reasons. First, in preclinical studies, lapatinib inhibited tumor growth in ErbB2-overexpressing breast ductal carcinoma cell lines. Given the virulent nature of ErbB2-positive disease and subsequent poor prognosis, lapatinib has the potential to be beneficial as treatment for women whose tumors overexpress the ErbB2 protein. Second, in clinical studies of metastatic breast cancer, lapatinib appeared to have activity and was well tolerated with few toxic effects in patients. Overall, the safety profile of lapatinib is distinctly different from that of conventional cytotoxic agents, and appears to be similar to that of hormonal agents. Finally, lapatinib offers a convenient daily oral route of administration which is preferable compared with an intravenous administration, especially in a long-term adjuvant setting.

To address the aforementioned unmet clinical need, the current study (EGF105485) will determine whether treatment with oral single-agent lapatinib in women with early-stage ErbB2-overexpressing breast cancer will improve disease-free survival. This study is designed to compare the efficacy and safety of lapatinib versus placebo in women who have no clinical or radiographic evidence of disease and have not been previously treated with trastuzumab. The current standard of care for women who have completed adjuvant chemotherapy and have no evidence of disease is close observation with or without the use of endocrine therapy. Therefore, the use of placebo as the control arm in this study is appropriate in this setting. Furthermore, no data are currently available to support the use of any other agents, including adjuvant trastuzumab, in these patients.

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2. OBJECTIVES

2.1. Primary Objective

The primary objective of the study is to determine whether adjuvant therapy with lapatinib will improve disease-free survival in women with early-stage ErbB2-overexpressing breast cancer.

2.2. Secondary Objectives

2.2.1. Efficacy

The secondary efficacy objectives of the study are:

• to determine whether adjuvant therapy with lapatinib will be superior to placebo in improving the following time-to-event endpoints:

• overall survival

• recurrence-free survival

• distant recurrence-free survival

• CNS recurrence-free survival

• to evaluate and compare between treatment arms the rate of CNS recurrence.

• to evaluate and compare between treatment arms the change in quality of life (QoL) relative to baseline using the Medical Outcomes Study (MOS) 36-item short-form (SF-36 v2) acute recall [Ware, 1992; McHorney, 1993; Ware, 2001] (refer to Section 14.6, Appendix 6 for health survey).

2.2.2. Safety

The secondary safety objectives of the study are:

• to determine the qualitative and quantitative toxicities associated with oral lapatinib administered daily versus placebo.

• to evaluate and compare between treatment arms the incidence of cardiac dysfunction.

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2.2.3. Translational Research

The translational research objective of the study is:

• to identify tumor-derived or blood-derived biomarkers (encoded in protein or RNA) that correlate with or are predictive of clinical response/benefit to lapatinib and genetic aberrations in somatic DNA derived from the tumor tissue obtained at the time of initial diagnosis (archived tumor tissue sample).

• to compare biomarkers derived from the archived tumor tissue sample to those derived from a tumor biopsy sample obtained at the time of disease recurrence

2.2.4. Pharmacogenetic Research

The pharmacogenetic (PGx) research objective of the study is:

• to investigate the relationship between genetic variations in select candidate genes in the host DNA and response (safety, efficacy and tolerability) following treatment with lapatinib (refer to Section 14.2, Appendix 2 for full details on PGx research of this study).

3. ENDPOINT(S)

3.1. Primary Endpoint

The primary efficacy endpoint for analysis is disease-free survival (DFS) which includes the following events:

• local recurrence following mastectomy

• local recurrence in ipsilateral breast following lumpectomy

• regional recurrence

• distant recurrence

• contralateral breast cancer, including ductal carcinoma in situ (DCIS)

• other second primary cancer (excluding squamous or basal cell carcinoma of the skin, melanoma in situ, carcinoma in situ of the cervix, or lobular carcinoma in situ of the breast)

• death from any cause without prior event (recurrence of breast cancer or second primary cancer)

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3.2. Secondary Endpoints

3.2.1. Efficacy

Secondary efficacy endpoints are:

• recurrence-free survival which includes the following events:





• contralateral breast cancer, including DCIS

• distant recurrence-free survival which includes the following events:


• overall survival which includes death from any cause

• CNS recurrence-free survival

• rate of CNS recurrence

• health-related QoL which includes summary measures of physical and mental health (component scores), independent dimension scores

3.2.2. Safety

The safety endpoints are:

• laboratory and non-laboratory toxicity;

• cardiac dysfunction which includes left ventricular cardiac dysfunction as defined in Section 7.2.2 and evaluation of QT/QTc interval (a specific sub-study evaluating the effect of lapatinib on QT/QTc interval will be conducted in selected investigative centers. A separate companion protocol has been written to encompass this study.

3.2.3. Translational Research

The translational research endpoints are:

• determination of the relationship between somatic genetic aberrations [mutations, deletions, amplifications in genes such as, ErbB1, ErbB2, phosphatase and tensin homolog (PTEN), etc.] in the pre-treatment biopsy that correlate with clinical response/benefit to lapatinib;

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• using immunohistochemistry (IHC) and transcriptional profiling or the like, determination of the relationship between baseline expression of intra-tumoral biomarkers [e.g., ErbB1, ErbB2, insulin-like growth factor-1 receptor (IGF1R)] from pre-treatment tumor biopsies and correlation with clinical response/benefit to lapatinib;

• comparison of biomarkers derived from the tumor tissue from initial diagnosis with those derived from the tumor tissue obtained at time of disease recurrence;

• evaluation of the protein profile in plasma samples at baseline and at disease recurrence that correlate with or are predictive of clinical response/benefit to lapatinib.


The PGx research endpoint is:

• evaluation of the presence/absence of genetic variations in select candidate genes in the host DNA and the response (safety, efficacy and tolerability) to lapatinib therapy.

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4. STUDY DESIGN

This is a randomized, double-blind, placebo-controlled, Phase III, adjuvant study comparing the efficacy and safety of lapatinib versus placebo. Women with early-stage ErbB2-overexpressing breast cancer who have not been previously treated with trastuzumab will be enrolled. Enrollment will occur after completion of primary adjuvant chemotherapy for those women who subsequently have no clinical or radiologic evidence of disease. The study design is shown in Figure 1.

Figure 1 Study Design for EGF105485

• time from initial diagnosis (</=4vs>4 yrs)

• lymph nodal involvement (+ vs–)

• hormone receptor status(ER+ and/or PgR+ vsER–and PgR–)

Treat until diseaserecurrence orsecond primary cancer

Long-tem follow-up for disease status and survival

Randomize

Arm A:Oral Lapatinib1500 mg QDfor 1 year1

Arm B:Oral matching placebo QDfor 1 year1

Women with invasive ErbB2+breast cancer and not previously treated with trastuzumab

NED by clinical & radiologicevaluation

Stratification

1. Treatment will continue for a maximum of 12 months or until disease recurrence or development of a second primary cancer, withdrawal from study drug due to unacceptable toxicity, or consent withdrawal (refer to Section 9 for further details on subject completion and withdrawal).

Abbreviations: NED = no evidence of disease; ER = estrogen receptor; PgR = progesterone receptor; QD = once daily. Women will be screened at baseline and those eligible will be randomly assigned in 1:1 fashion to receive adjuvant therapy with either double-blind lapatinib (Arm A) or placebo (Arm B). During the blinded treatment period, lapatinib 1500mg or matching placebo will be administered orally QD (refer to Section 7.3 for rationale for dose selection of lapatinib). Treatment will continue for a maximum of 12 months (1 year) or until disease recurrence or development of a second primary cancer, unacceptable toxicity, or consent withdrawal (refer to Section 9 for further details on subject completion and withdrawal). Screening assessments and clinical safety, health-related QoL, and efficacy evaluations to assess toxicity and response to the study drug will be performed according to the Time and Events Table (refer to Section 14.1, Appendix 1). Women enrolled in the clinical study are eligible for participation in the PGx research; however, participation is optional (refer to Section 14.2, Appendix 2 for details on PGx research for this study). Women enrolled in the clinical study who have a recurrence of their disease are eligible for participation in additional translational research; however, participation is optional (refer to Section 6.5.1 for details on translational research for this study). In addition, a sub-study will be conducted. A subset of women enrolled in the clinical protocol will be eligible to participate in a specific sub-study evaluating QT/QTc interval. This sub-study

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will be conducted in selected investigative centers and a separate companion protocol has been written to encompass this study. Participation is optional.

During the enrolment period of this study, certain demographic characteristics (time interval from completion of primary adjuvant chemotherapy to randomization and time interval from initial diagnosis to randomization) will be monitored. To avoid an overrepresentation of any one subgroup in this heterogeneous population, Massachusetts General Hospital (MGH) and GSK reserve the right to curtail accrual. The decision to suspend enrollment of certain overrepresented subgroups will be made by the Study Committee and will be communicated to investigative centers directly and expediently in the form of a letter.

After study drug withdrawal or completion of 12-month treatment period, all women will be assessed for information on survival and additional anti-cancer therapies. For women who withdraw from or complete treatment without recurrence of disease or development of a second primary cancer, clinical assessments of disease status will continue. The frequency of efficacy assessments will vary depending on the time interval between the date of initial diagnosis and the date of study drug withdrawal or completion. Assessment of efficacy will continue until death with evaluations as outlined according to Table 4.

Table 4 Efficacy Assessments after Study Drug Withdrawal or Completion of 12-Month Treatment Period

Time from Initial Diagnosis to Study Drug Withdrawal or Completion

Frequency of Assessments1

≤2 years every 3 months until >2 years post-diagnosis2 >2 to 5 years every 6 months until >5 years post-diagnosis2 >5 years

every 12 months until death or until 10 years after the date of study drug withdrawal or completion, whichever comes first

1. assessments include evaluation of disease recurrence or second primary cancer in women who discontinued or completed the study drug without evidence of disease recurrence or second primary cancer, and evaluation of survival and anti-cancer therapies in all women.

2. once the stated post-diagnosis time point is met, refer to the next line in the table. The frequency of efficacy assessments (evaluation of disease status, survival and anti-cancer therapies) in the follow up phase will be determined according to Table 4. However, all safety and health-related QoL assessments in the follow up phase must be performed in all women at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1.

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The primary analysis (after 463 women have disease recurrence, a second primary cancer, or have died) will test whether lapatinib is superior to placebo with respect to DFS. One interim analysis will be performed after 309 women have disease recurrence, a second primary cancer, or have died. A Haybittle-Peto stopping boundary will be used to detect superiority of lapatinib. To preserve the integrity of the study blind, an Independent Data Monitoring Committee (IDMC) will be convened to periodically review the accumulating safety and the efficacy and safety data for the interim analysis. The results of the interim analyses will only be known to the IDMC, and any recommendation to terminate the trial would not be based solely on statistical grounds (refer to Section 11.3.3 for details on the IDMC and interim analysis).

5. STUDY POPULATION

5.1. Number of Subjects

Approximately 3000 women will be enrolled over a 24-month enrolment period. This study will be conducted at approximately 340 investigative sites globally. Approximately 1500 women will be randomized to the lapatinib treatment arm and 1500 women will be randomized to the placebo treatment arm (refer to Section 11.2 for further details on sample size).

5.2. Eligibility Criteria

5.2.1. Inclusion Criteria

Women will be eligible for inclusion in this study only if all of the following criteria apply:

1. Have histologically or cytologically confirmed ErbB2-overexpressing invasive carcinoma (Tx or T1-4) of the breast at the time of the initial diagnosis and have undergone adequate excision of tumor;

2. Had tumors that overexpress ErbB2 defined as either:

• 3+ by IHC

OR

• c-erbB2 gene amplification by FISH

OR

• 0, 1+, 2+ by IHC and c-erbB2 gene amplification by FISH.

The status of ErbB2 expression/amplification must be documented by a local laboratory or the central laboratory prior to study entry; however, a tumor tissue sample must be sent to the central laboratory for subsequent re-analysis of ErbB2 status;

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3. Using the American Joint Committee on Cancer (6th edition) staging criteria for breast cancer [Greene, 2002] (refer to Section 14.3, Appendix 3), a woman must have Stage I through Stage IIIc disease meeting one of the following criteria:

• node-positive disease defined as one positive lymph node by sentinel node biopsy OR at least 1 positive lymph node found among at least 6 axillary nodes examined on axillary node dissection OR status post axillary radiotherapy for sterilization if clinically evaluated as cN1 or cN2 (if sentinel node biopsy is positive, subject may either undergo an axillary node dissection or radiotherapy to the axilla).

node-positive disease must be evaluated as the following:

• by clinical evaluation, ipsilateral axillary lymph nodes must be cN0-2;

• by pathological evaluation, axillary lymph nodes must be pNX, pN0(i+), or pN1-3; for pN0(I+), axillary dissection will be at the discretion of the investigator; for subjects with pN3 (Stage IIIc disease), subjects must be disease free (as determined by physical examination, medical history, and mammogram of preserved breast and/or contralateral breast) following completion of neoadjuvant or adjuvant chemotherapy for at least 12 months and must not have been lost to follow up.

OR

• node-negative disease defined as negative sentinel node biopsy OR no positive lymph nodes found among at least 6 axillary nodes examined on axillary node dissection OR status post axillary radiotherapy for sterilization if clinically evaluated as cN0.

node-negative disease must be categorized as either:

• high-risk disease defined as:

• tumor >2.0 cm if ER and/or progesterone receptor (PgR) positive disease is present OR tumor >1.0 cm if ER and PgR negative disease;

OR

• intermediate-risk disease defined as:

• tumor 1.0-2.0 cm and ER and/or PgR positive disease.

4. Women with synchronous bilateral invasive breast cancer or synchronous DCIS of either the contralateral or ipsilateral breast at the time of the initial diagnosis are also eligible; prior endocrine therapy as treatment for or as primary prevention of DCIS is allowed.

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5. Have completed all primary neoadjuvant or adjuvant chemotherapy regimens prior to study enrollment. However, adjuvant endocrine therapy and radiotherapy may continue as described in Inclusion Criteria #11 and #13, respectively. For women who received an anthracycline-based adjuvant regimen, the interval between the completion of this therapy and study entry must be at least 4 weeks and all therapy-related toxicity must be resolved.

6. All women eligible for adjuvant treatment with trastuzumab, including those diagnosed and treated within the last six months, must be considered for such treatment prior to being offered participation in this study. Participation in this study will be allowed only if the physician and patient have considered and discussed at length the advantages of trastuzumab, but have mutually decided against initiating trastuzumab therapy. Clear documentation of such a decision must appear in the Electronic Case Report Form (eCRF). Reasons for such decisions may include (but are not limited to) living remote to the nearest infusion center and inability to travel weekly for treatment infusions, lack of intravenous access and refusal to obtain indwelling devices;

7. Have clinical and radiologic assessments, as described below, that are negative for local or regional recurrence of disease or metastatic disease at the time of study entry:

• clinical assessment:

• if signs or symptoms suggestive of either recurrence of disease or metastatic disease are present, the appropriate radiological imaging must be performed;

• laboratory and radiologic assessments:

• if the following laboratory results are present, the appropriate radiological imaging must be performed:

Laboratory Value Radiological Imaging AST ≥2 × ULN abdominal CT or MRI scan ALT ≥2 × ULN abdominal CT or MRI scan ALP ≥2 × ULN (not in the bone fraction) abdominal CT or MRI scan ALP ≥2 × ULN in the bone fraction bone scan; a confirmatory x-ray, CT scan or MRI

scan or biopsy is required if the results of the bone scan are inconclusive

Abbreviations: ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; CT = computed tomography; MRI = magnetic resonance imaging; ULN = upper limit of normal • bilateral mammogram required if not performed within 12 months prior to study

entry. If the initial surgery was a total mastectomy, only a mammogram of the remaining breast is required. If the initial surgery was a bilateral mastectomy, only the clinical and other radiologic assessments, as described above, are required.

8. Must have had an analysis of both ER and progesterone receptor (PgR) on the primary tumor prior to study entry;

9. Have undergone either mastectomy OR lumpectomy;

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10. Must have received a prior neoadjuvant or adjuvant chemotherapy regimen containing either an anthracycline or a taxane; or any cyclophosphamide, methotrexate and 5-fluorouracil (CMF) regimen;

11. May continue to receive endocrine therapy, including tamoxifen or an aromatase inhibitor, while taking study medication, if endocrine therapy was initiated as either adjuvant therapy for treatment of the initial diagnosis of invasive breast cancer or for ovarian function suppression; however, endocrine therapy may not be initiated while taking study medication. Endocrine therapy agents may be switched while participating in this study (e.g., stop tamoxifen and start letrozole);

12. May have received prior radiotherapy as treatment for primary tumor; however, is not required for study entry;

13. May continue to receive radiotherapy while taking study medication, if radiotherapy was initiated as adjuvant therapy for treatment of the initial diagnosis of invasive breast cancer;

14. May continue to receive bisphosphonates only for treatment of documented osteoporosis, but not as treatment or prophylaxis of bone metastases;

15. Have not received prior therapy with an ErbB1 and/or ErbB2 inhibitor;

16. Have a cardiac ejection fraction within institutional range of normal as measured by either echocardiogram or multigated acquisition (MUGA) scans. The same method of cardiac evaluation must be used consistently throughout the study;

17. Have an Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 to 1 (refer to Section 14.4, Appendix 4) [Oken, 1982];

18. Women with a history of non-breast malignancies are eligible if they have been disease-free for at least 5 years and are deemed by the investigator to be at low risk for recurrence. Women with the following cancers are eligible if diagnosed and treated within the past 5 years: cervical carcinoma in situ, melanoma in situ, and basal cell or squamous cell carcinoma of the skin;

19. Are able to swallow and retain oral medication;

20. Have an archived tumor tissue sample available for biomarker analysis. It is preferable that a paraffin-embedded tissue block from an archived tumor tissue from the primary tumor be submitted. However, for sites that do not allow submission of tumor blocks, it is recommended twenty (20) slides of paraffin-embedded tissue be submitted instead;

21. Are able to complete all screening assessments as outlined in the protocol;

22. Have adequate organ function as defined in Table 5:

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Table 5 Baseline Laboratory Values

System Laboratory Value Hematologic absolute neutrophil count ≥1.5 × 109/L hemoglobin ≥9 g/dL platelets ≥75 × 109/L Hepatic albumin ≥2.5 g/dL serum bilirubin ≤1.25 × ULN aspartate aminotransferase ≤3 × ULN alanine aminotransferase ≤3 × ULN Renal serum creatinine ≤2.0 mg/dL - OR - calculated creatinine clearance1 ≥40 mL/min 1. calculated by the Cockcroft and Gault Method (refer to Section 14.5, Appendix 5) [Cockcroft, 1976]. Abbreviations: ULN = upper limit of normal

23. Have signed the informed consent form (ICF);

24. Are aged ≥ 18 years with any menopausal status;

• Non-child-bearing potential (i.e., women with functioning ovaries who have a current documented tubal ligation or hysterectomy, or women who are postmenopausal);

• Child-bearing potential (i.e., women with functioning ovaries and no documented impairment of oviductal or uterine function that would cause sterility.) This category includes women with oligomenorrhea (severe), women who are perimenopausal, and young women who have begun to menstruate. These subjects must have a negative serum pregnancy test at screening and agree to one of the following:

• Complete abstinence from intercourse or consistent and correct use of one of the following acceptable methods of birth control from 2 weeks prior to administration of the first dose of study medication until 28 days after the final dose of study medication:

• male partner who is sterile prior to the female subject's entry into the study and is the sole sexual partner for that female subject;

• implants of levonorgestrel, where not contraindicated for this patient population or per local practice;

• injectable progestogen, where not contraindicated for this patient population or per local practice;

• any intrauterine device with a documented failure rate of less than 1% per year;

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• oral contraceptives (progestogen only), where not contraindicated for this patient population or per local practice; or

• barrier methods, including diaphragm or condom with a spermicide

5.2.2. Exclusion Criteria

Women will not be eligible for inclusion in this study if any of the following criteria apply:

1. Have clinical and radiologic evidence of local or regional recurrence of disease or metastatic disease at the time of study entry;

2. Had metachronous invasive breast cancer (breast cancers diagnosed at different times);

3. Have a prior history of other breast cancer malignancies, including DCIS;

4. Are unable to provide archived tumor tissue samples for assay;

5. Had prior therapy with an ErbB1 and/or ErbB2 inhibitor; women who experienced a hypersensitivity or allergic reaction to trastuzumab during the first infusion and were unable to complete this infusion are eligible;

6. Receive concurrent anti-cancer therapy (chemotherapy, immunotherapy, and biologic therapy) while taking study medication;

7. Have unresolved or unstable, serious toxicity from prior administration of another investigational drug and/or of prior cancer treatment;

8. Have malabsorption syndrome, disease significantly affecting gastrointestinal function, or resection of the stomach or small bowel. Women with ulcerative colitis are also excluded;

9. Have a concurrent disease or condition that would make the woman inappropriate for study participation, or any serious medical disorder that would interfere with the woman's safety;

10. Have an active or uncontrolled infection;

11. Have dementia, altered mental status, or any psychiatric condition that would prohibit the understanding or rendering of informed consent;

12. Have a known history of uncontrolled or symptomatic angina, arrhythmias, or CHF;

13. Are pregnant or breastfeeding;

14. Receive concurrent treatment with an investigational agent; women, who are in follow-up in another clinical trial where the primary endpoint has been met and the interval between assessments is ≥12 months and radiological imaging is not required at these assessments, are eligible;

15. Receive concurrent treatment with prohibited medications (refer to Section 8.2 for details on prohibited medications);

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16. Used an investigational drug within 30 days or 5 half-lives, whichever is longer, preceding the first dose of study medication;

17. Have a known immediate or delayed hypersensitivity reaction or idiosyncrasy to drugs chemically related to lapatinib or excipients;

18. In France, subjects are neither affiliated with nor a beneficiary of a social security category.

5.2.3. Other Eligibility Criteria Considerations

To assess any potential impact on subject eligibility with regard to safety, the investigator must refer to the following document(s) for detailed information regarding warnings, precautions, contraindications, adverse events, and other significant data pertaining to the investigational product being used in this study: IB for lapatinib and the Study Reference Manual (SRM).

Eligibility criteria required for participation in PGx research is presented in Section 14.2, Appendix 2.

6. STUDY ASSESSMENTS AND PROCEDURES

Study assessments and procedures are described herein. For the timing of all assessments, refer to the Time & Events Table in Section 14.1, Appendix 1.

Medical and physical examinations should be performed by a qualified physician and should include a thorough review of all body systems. Study-relevant data will be captured in the eCRF and originate from source documentation which is comprised of the study relevant data/assessments as well as the remaining data captured during the medical and physical examination of the subject.

6.1. Demographic and Baseline Assessments

A signed, written ICF must be obtained prior to all screening and baseline assessments, and before any study-specific assessments are initiated, including obtaining archived tumor tissue for biomarker analysis. In addition, evaluation of inclusion and exclusion criteria and documentation of ErbB2 expression must be obtained prior to all screening and baseline assessments, and before any study-specific assessments are initiated. If at screening, a procedure or assessment has been completed as part of the standard routine care and the procedure meets the protocol-defined criteria and has been performed in the timeframe of the study, the test will not be required to be repeated unless clinically indicated.

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The following baseline demographic evaluations should be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Demographic data: date of birth, geographic ancestry, gender, height, body weight, and menopausal status;

• Disease and anti-cancer treatment history: date of first diagnosis, histology and tumor stage at first diagnosis, lymph node status, and hormone receptor status; and prior therapies, including surgery, chemotherapy, radiotherapy, biological and hormonal.

• Confirmation of ErbB2 overexpression status (3+ by IHC or FISH+). To confirm eligibility for the study, IHC and/or FISH may be performed locally; however, a central laboratory will subsequently confirm IHC tests. Additional tumor tissue will be required for biomarker and tumor genetic analysis and may be sent at this time or as soon as possible after randomization (refer to the SRM for shipping and handling instructions).

The following baseline safety evaluations must be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Physical examination: vital signs (blood pressure, body temperature, and heart rate) and ECOG performance status (refer to Section 14.4, Appendix 4);

• Cardiac evaluation (refer to Section 6.2.3);

• Baseline signs and symptoms assessed using the NCI CTCAE (Version 3.0) [National Cancer Institute, 2005];

• Prior and concomitant medication(s) within 4 weeks of the first dose of study medication;

• Laboratory assessments (refer to Section 6.2.1);

• Serum pregnancy for all women of childbearing potential (refer to Section 6.2.2).

Physical examination, baseline signs and symptoms, concomitant medications, and laboratory results must be reviewed (prior to administration of first dose of study drug) and may be repeated if necessary.

The following baseline efficacy evaluations must be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Clinical outcome (refer to Section 6.3.1);

• Health-related QoL questionnaire, the SF-36v2 (refer to Section 6.4);

NOTE: The initial assessment of health-related QoL must be performed prior to administration of the first dose of study drug. The SF-36v2 questionnaire must be completed prior to any other study procedures being performed, including physician interaction.

• Biomarker(s) evaluation (refer to Section 6.5).

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NOTE: After all screening evaluations have been completed and the data are obtained, the inclusion and exclusion criteria must be reviewed to confirm eligibility (refer to Section 5.2).

6.2. Safety

The specific details for timing of all safety assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, safety assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Safety assessments during the follow up phase may be performed up to 7 days before and up to 7 days after the scheduled visit to the site. To further facilitate scheduling, cardiac evaluation by echocardiogram or MUGA during the study drug treatment and follow up phases may be performed up to 14 days before or after the scheduled visit to the site. Any assessment may be performed more frequently if clinically indicated.

To ensure a timely assessment of safety in patients who prematurely discontinue study drug or complete the 12-month study drug treatment phase, the Early Study Withdrawal Visit/Month 12 Visit should occur on or as soon as possible after early discontinuation or completion of study drug day.

The following safety assessments will be performed in this study:

• Physical examination including vital signs and ECOG Performance Status (refer to Section 14.4, Appendix 4);

• Adverse event (AE) and serious adverse event (SAE) assessment (refer to Section 10) and grading according to the NCI CTCAE (Version 3.0) [National Cancer Institute, 2005];

• Concomitant medication(s) added and/or changed;

• Cardiac evaluation by ECG and echocardiogram or MUGA (refer to Section 6.2.3);

• The women and/or family member will be instructed to telephone the site with any changes in mental or physical status or questions about the study drug;

• Laboratory assessments (refer to Section 6.2.1).

NOTE: Following withdrawal from study drug, a cardiac evaluation by echocardiogram or MUGA will be performed between 6 to 9 months after discontinuation of study drug on all women.

6.2.1. Laboratory Assessments

All protocol required laboratory assessments, as defined in Table 6, should be performed by the central laboratory, Quest Diagnostics. Laboratory requisition forms must be completed and samples must be clearly labelled with the subject number, protocol number, site/center number, and visit date. Details for the preparation and shipment of samples will be provided by Quest Diagnostics. Reference ranges for all safety parameters will be provided to the site by Quest Diagnostics.

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If additional laboratory assessments are performed at the institution’s local laboratory, all laboratory results must be documented on the eCRF and reference ranges and safety parameters must be provided to GlaxoSmithKline (GSK).

Table 6 Laboratory Assessments

Hematology Standard Chemistry1 hemoglobin sodium hematocrit potassium red blood cell count calcium platelets glucose white blood cell count with differential blood urea nitrogen or urea total neutrophils creatinine2 lymphocytes AST monocytes ALT eosinophils alkaline phosphatase basophils total bilirubin4 total protein albumin Serum Pregnancy3 serum β-hCG (human chorionic gonadotrophin) 1. chemistry evaluation of bicarbonate, chloride, and uric acid are not required where there are logistical constraints 2. if serum creatinine is >2.0 mg/dL, calculate creatinine clearance using standard Cockcroft and Gault method (refer

to Section 14.5, Appendix 5) [Cockcroft, 1976]. 3. refer to Section 6.2.2 for further details on serum pregnancy testing. 4. bilirubin fractionation is recommended if total bilirubin >2 × ULN when testing is available Prior to administration of the first dose of study drug, results of laboratory assessments should be reviewed. Any laboratory test with a value outside the normal range will be repeated (prior to the first dose) at the discretion of the investigator. Before the first dose of study drug, all laboratory results must be within the values outlined in Section 5.2.1, Table 5). All laboratory tests with values that are significantly abnormal during participation in the study or within 30 days after the last dose of study drug should be repeated until the values return to normal or baseline. If such values do not return to normal within a period judged reasonable by the investigator, the etiology should be identified and the sponsor notified. Standard chemistry must be performed every 6 weeks or more frequently if clinically indicated during the study drug treatment phase to allow for close monitoring of liver chemistry results (refer to Section 7.2.2.2 for liver chemistry stopping rules and follow up criteria).

6.2.2. Pregnancy

A screening serum β-hCG (human chorionic gonadotrophin) pregnancy test is mandatory for all women of childbearing potential within 4 weeks prior to the first dose of investigational product. Thereafter, the serum pregnancy test need only be repeated if clinically indicated or as required by local regulation.

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6.2.2.1. Time period for collecting pregnancy information

The time period for collecting pregnancy information is identical to the time period for collecting AEs, as stated in Section 10.4. Pregnancy information is collected from the first dose of study drug to 5 days after the last dose.

6.2.2.2. Action to be taken if pregnancy occurs

The investigator will collect pregnancy information on any female subject, who becomes pregnant while participating in this study. The investigator will record pregnancy information on the appropriate form and submit it to GSK within 2 weeks of learning of a subject's pregnancy. The subject will also be followed to determine the outcome of the pregnancy. Information on the status of the mother and child will be forwarded to GSK. Generally, follow-up will be no longer than 6 to 8 weeks following the estimated delivery date. Any premature termination of the pregnancy will be reported.

While pregnancy itself is not considered to be an AE or SAE, any pregnancy complication or elective termination of a pregnancy for medical reasons will be recorded as an AE or SAE (refer to Section 10 of the protocol and the SRM for definitions and a description of follow-up).

A spontaneous abortion is always considered to be an SAE and will be reported as such. Furthermore, any SAE occurring as a result of a post-study pregnancy and is considered reasonably related to the investigational product by the investigator, will be reported to GSK as described in section entitled, "Post-study AEs and SAEs" of the SRM. While the investigator is not obligated to actively seek this information in former study participants, he or she may learn of an SAE through spontaneous reporting.

6.2.3. Cardiac Assessment

The following cardiac evaluations must be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Cardiac evaluation by electrocardiogram (12-lead ECG) and echocardiogram or MUGA. Echocardiogram will be performed to evaluate LVEF. If echocardiogram cannot be performed or if the investigator feels it is not conclusive to evaluate LVEF, then a MUGA scan should be done; however, the same method of cardiac evaluation must be used consistently throughout the study;

• Echocardiogram will be performed under the supervision of an experienced cardiologist, presumably at the same high-volume laboratory for the duration of the study. The guidelines of the American Society of Echocardiography (ASE) should be considered (refer to the SRM for ASE recommendations for the use of echocardiogram in clinical trials);

• Cardiac evaluation by echocardiogram or MUGA will be performed at screening, at Months 3, 6, 9, and 12 during the treatment period and between 6 to 9 months after discontinuation of study drug on all women. Subjects who develop clinical signs or

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symptoms of cardiac failure should undergo a cardiac evaluation by 12-lead ECG and echocardiogram or MUGA.

• Cardiac safety will also be monitored by applying an algorithm for the continuation or discontinuation of study drug according to LVEF assessment (refer to Figure 2 in Section 7.2.2.1).

6.2.3.1. Definitions and Cardiac Monitoring

A cardiac event will be classified as a primary or secondary cardiac endpoint if the event meets the criteria as defined herein.

6.2.3.1.1. Primary Cardiac Endpoints

• Cardiac death defined as either:

• Cardiac death due to heart failure, myocardial infarction or arrhythmia or;

• Probable cardiac death defined as sudden, unexpected death within 24 hours of a definite or probable cardiac event.

• Severe symptomatic congestive heart failure (CHF) defined as:

• New York Heart Association (NYHA) Class III (not capable of climbing one flight of stair) or Class IV (having symptoms at rest) AND an absolute decrease in LVEF of more than 10 percentage points from baseline AND to an LVEF value below 50% [The Criteria Committee of the New York Heart Association, 1994p].

NOTE: a second LVEF assessment is NOT needed to confirm the event. However, if a subject experiences severe symptomatic CHF as defined above, cardiac evaluation by echocardiogram or MUGA must be performed every 4 weeks for at least 16 weeks or until resolution.

6.2.3.1.2. Secondary Cardiac Endpoint

• Asymptomatic or mildly symptomatic cardiac event defined as:

• NYHA Class I (asymptomatic) or NYHA Class II (mildly symptomatic) significant decrease in LVEF defined as an absolute decrease in LVEF of more than 10 percentage points from baseline AND to an LVEF value below 50% [The Criteria Committee of the New York Heart Association, 1994p].

NOTE: a second LVEF assessment must be performed within approximately three weeks to confirm the significant decrease in LVEF as defined above. If a subject has a confirmed secondary cardiac event as defined above, cardiac evaluation by echocardiogram or MUGA must be performed every 4 weeks for at least 16 weeks or until resolution.

6.2.3.2. Stopping and Holding Rules

• If an absolute difference of more than 4% increase in the incidence of primary cardiac endpoints is observed on the lapatinib treatment arms compared with

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placebo, the Independent Data Monitoring Committee (IDMC) will consider recommending stopping or modifying the trial.

• Rationale for the >4% stopping rule: the incidence of NYHA Class III or IV CHF or possible/probable cardiac death among patients treated with adjuvant trastuzumab in the NSABP-B 31 trial was 4.1%; this was the highest recorded incidence of trastuzumab-associated CHF in any of the recently reported adjuvant trastuzumab breast cancer trials (refer to Table 3) [Romond, 2005].

• If a subject experiences a primary cardiac event, then study drug will be permanently discontinued. If a subject experiences an asymptomatic or mildly symptomatic cardiac event, the decision to continue or discontinue study drug is based on the algorithm in Figure 2 in Section 7.2.2.1.

6.2.3.3. Treatment

It is strongly recommended that subjects who experience a symptomatic decrease in LVEF or meet the criteria for permanently discontinuing study drug seek cardiologic consultation for potential treatment for cardiac dysfunction.

6.3. Efficacy

6.3.1. Clinical Outcome Assessment

The primary efficacy endpoint for this trial is DFS (as defined in Section 3.1 and Section 11.3.5.1). Secondary efficacy endpoints include recurrence-free survival, distant recurrence-free survival, CNS recurrence-free survival time and rate of CNS recurrence, and overall survival.

Women must have no clinical or radiographic evidence of disease at the time of study entry. The specific details for timing of all clinical outcome assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, efficacy assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Efficacy assessments during the follow up phase may be performed up to 21 days before and up to 21 days after the scheduled visit to the site. To further facilitate scheduling, mammography during the study drug treatment phase may be performed up to 14 days before or after the scheduled annual test and during the follow up phase may be performed up to 21 days before or after the scheduled annual test. Any assessment may be performed more frequently if clinically indicated.

To ensure a timely assessment of efficacy in patients who prematurely discontinue study drug or complete the 12-month study drug treatment phase, the Early Study Withdrawal Visit/Month 12 Visit should occur on or as soon as possible after early discontinuation or completion of study drug day.

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The following efficacy assessments will be performed in this study for the aforementioned primary and secondary efficacy endpoints:

• Clinical assessment, including medical history, physical examination, for possible palpable lesions (i.e., lymph nodes) or visual lesions (i.e., skin nodules), and evaluation of other signs and symptoms that may be suggestive of disease recurrence or a second primary cancer;

• Radiologic assessment:

• Bone scan to include evaluation of skull, total spine, clavicle, ribs, pelvis, and long bones (only required if bone fraction of ALP ≥2 × ULN or symptoms suggestive of disease recurrence are present);

• Chest CT scan or MRI scan to include the entire liver, or alternatively, separate chest and abdominal CT (or MRI) scans [only required if AST, ALT or ALP ≥2 × ULN (not in the bone fraction), or symptoms suggestive of disease recurrence are present];

• Bilateral mammography (unilateral for patients with mastectomy and not applicable for patients with bilateral mastectomy) (only required if not performed within 12 months prior to study entry);

• MRI of the head (only required if neurological symptoms suggestive of disease recurrence are present).

NOTE: A positive positron emission tomography (PET) scan is not an acceptable method to evaluate disease status and needs to be confirmed by a CT scan, MRI scan, or x-ray. A positive ultrasound is not an acceptable method to evaluate disease status and needs to be confirmed by a biopsy.

All women who withdraw from study drug before disease recurrence or development of second primary cancer will continue to be assessed for efficacy according to the evaluations outlined in Table 4.

Refer to Section 6.3.1.1 for details on the acceptable criteria for diagnosis of disease recurrence (Section 6.3.1.1.1) or second primary cancer (Section 6.3.1.1.2).

6.3.1.1. Definitions and Diagnosis Criteria for Disease Recurrence and Second Primary Cancer

A woman may be diagnosed with disease recurrence (local, regional or distant) or a second primary cancer (breast and non-breast) only if the radiologic and/or laboratory findings meet the criteria as defined herein.

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6.3.1.1.1. Disease Recurrence

Local recurrence

Local recurrence is defined as invasive or in situ breast cancer [not including lobular carcinoma in situ (LCIS)] occurring in the ipsilateral breast following lumpectomy, or in any soft tissue or skin of the ipsilateral chest wall following mastectomy. The latter site is an area bounded superiorly by the clavicle, inferiorly by a horizontal line at the level of the xiphisternum, medially by the midline, and laterally by the posterior axillary line.

• Acceptable criteria for diagnosis: positive cytology, needle aspiration or biopsy Regional recurrence

Regional recurrence is defined as a tumor in the ipsilateral internal mammary, ipsilateral supraclavicular, ipsilateral infraclavicular and/or ipsilateral axillary nodes, and the soft tissue of the ipsilateral axilla following surgical intervention.

• Acceptable criteria for diagnosis: positive cytology, needle aspiration or biopsy; histologic or cytologic confirmation of tumor is recommended for ipsilateral internal mammary or infraclavicular/high axillary nodal recurrence.

Distant recurrence

Distant recurrence (metastatic disease) is defined as a tumor in any area of the body not including those defined as local or regional recurrence.

Sites of distant recurrence include:

• Skin, subcutaneous tissue, and lymph nodes (excluding those described for local and regional recurrence)

• Acceptable criteria for diagnosis: positive cytology, needle aspiration or biopsy; OR radiologic evidence of metastatic disease.

• Bone marrow

• Acceptable criteria for diagnosis: positive cytology, needle aspiration or biopsy; OR radiologic evidence (MRI scan) of metastatic disease.

• Skeletal

• Acceptable criteria for diagnosis: positive biopsy; OR radiologic evidence (x-ray, CT scan or MRI scan) of lytic or blastic lesions consistent with metastatic disease; OR positive bone scan for metastatic disease.

NOTE: If diagnosis is equivocal by bone scan, a biopsy or CT scan or MRI scan is strongly recommended. A positive bone scan in a joint or in a recently traumatized area cannot be used as criterion for a diagnosis of distant recurrence. In asymptomatic women with an abnormal bone scan, progressive bone scan changes over 4 weeks showing new lesion development is required.

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• Lungs and pleural

• Acceptable criteria for diagnosis: positive cytology, needle aspiration or biopsy; OR radiologic evidence of multiple pulmonary nodules consistent with metastatic disease.

NOTE: If radiologic evidence is of a solitary lung lesion, further investigations (needle aspiration or biopsy) should be performed.

• Ascites and pleural effusions

• Acceptable criteria for diagnosis: positive cytology.

• Liver and other viscera

• Acceptable criteria for diagnosis: positive biopsy; OR radiologic evidence (abdominal CT, MRI, or liver scan) consistent with metastatic disease.

NOTE: If radiologic evidence is not definitive (evidence of a solitary liver lesion), a biopsy should be performed. However, if a biopsy is not performed, serial scans should be performed to assess stability or progression.

• Central nervous system

• Acceptable criteria for diagnosis: positive cytology or biopsy (for diagnosis of meningeal involvement); OR radiologic evidence (head CT or MRI scan) consistent with metastatic disease.

6.3.1.1.2. Second Primary Cancer

Second primary breast cancer

Second primary breast cancer is defined as invasive or in situ breast cancer (not including LCIS) occurring in the contralateral breast or chest wall.

• Acceptable criteria for diagnosis: positive histology. Second primary non-breast cancer

Second primary non-breast cancer is defined as any non-breast second primary cancer other than squamous or basal cell carcinoma of the skin, melanoma in situ, or carcinoma in situ of the cervix.

• Acceptable criteria for diagnosis: positive histology.

6.3.1.2. Dating of Disease Recurrence and Second Primary Cancer

The date of the procedure (e.g., needle aspiration, biopsy or radiologic imaging) establishing the diagnosis of disease recurrence or second primary cancer will be used as the date of first recurrence or new cancer. For example, if a suspicious palpable lesion in the ipsilateral breast is assessed during the clinical evaluation, the date of the needle aspiration or biopsy which established the diagnosis will be used.

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If the diagnosis of disease recurrence or second primary cancer is established with radiologic imaging, the date of the first positive record will be used.

6.4. Health Outcomes

Health-related Quality of Life (HRQoL) and health status will be assessed using subject self-completion of the SF-36v2, a general health-related QoL metric [Ware, 1992; McHorney, 1993; Ware, 2001] (refer to Section 14.6, Appendix 6 for health survey). Quality of life data will be analyzed to determine if there are treatment differences between the treatment cohorts.

The SF-36 will be completed at baseline (prior to administration of first dose of study drug) and prior to any other study procedures, including physician interaction. During the study treatment period, the SF-36v2 will be completed every 6 months (i.e., at Month 6 and Month 12). After withdrawal from study drug, the SF-36v2 will be completed every 6 months for 24 months. The timing of health-related QoL assessment is provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, health-related QoL assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Health-related QoL assessments during the follow up phase may be performed up to 21 days before and up to 21 days after the scheduled assessment.

The SF-36v2 produces an eight scale profile [physical function, role limitations due to physical problems (role physical), bodily pain, general health perceptions (general health), vitality, social function, role limitations due to emotional problems (role emotional), and mental health] and two summary indexes for physical and mental health. In the SF-36v2, each of 8 health attributes are measured using multi-item scales, each containing between 2 and 10 items.

The SF-36v2 is a generic measure of health rather than one which targets a specific age, disease, or treatment group. A generic health status questionnaire will enable baseline health status among subjects to be established, documentation of the instrument’s responsiveness to health status changes among this patient population, and exploration of the instrument’s sensitivity over an extended period of treatment and follow-up. Greater scores correspond to greater quality of life.

6.5. Translational Research

6.5.1. Tumor Tissue

All patients enrolled in the clinical trial are required to participate in the following translational research described herein. Paraffin-embedded tissue blocks (or sections) from archived tumor tissue samples (from time of original diagnosis) will be tested retrospectively to determine biomarkers (for example, ErbB1/2, PTEN, AKT, MAPK, ErbB1 and ErbB2 receptors) that correlate with or are predictive of clinical response/ benefit to lapatinib using appropriate technologies including transcriptional profiling and IHC.

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Patients enrolled in the clinical trial are also eligible to participate in additional translational research; however, participation is optional. Ample evidence exists to link primary genetic aberrations (mutations, amplifications, and deletions) with both disease progression and response to targeted therapies. Therefore, analysis of genetic aberrations in somatic DNA derived from the archived tumor tissue sample will be performed. In addition, a tumor tissue biopsy will be obtained from patients who have recurrence of their disease. The biomarkers derived from the archived tumor tissue sample will be compared with the biomarkers derived from the tumor tissue biopsy taken from the site of disease recurrence.

Approximately twenty (20) slides of paraffin-embedded tissue (or a tissue block of sufficient size to make 20 slides) from the tumor obtained at the initial diagnosis (archived tumor tissue) should be sent to GSK for testing. In addition, twenty (20) slides should be sent from the paraffin-embedded tissue biopsy taken from the site of disease recurrence. Analyses will be carried out at GSK laboratories or laboratories associated with GSK in the United States and/or Europe.

6.5.2. Plasma

Proteomic analyses of blood plasma samples will be conducted to identify any changes in the protein profile that can be related to the treatment response or to the occurrence of adverse events. Examination of pre-dosing (screening) plasma protein profiles may uncover novel blood-borne protein candidate biomarkers/profiles which could be used to predict drug response. Examination of protein profiles at relapse may yield novel blood-borne protein candidate biomarkers which relate to either the action of lapatinib or disease progression.

A 5 ml sample of blood for proteomic analyses will be drawn at the beginning of the study (pre-treatment), and at the time of relapse for those patients that relapse. Instructions on sample preparation, storage and shipping are provided in the SRM.

Plasma protein studies will be performed by 2-D gel separation or an alternative fractionation method. Individual proteins exhibiting statistically acceptable changes when comparing pre- and post-treatment levels from the same patient and which appear to be associated with treatment outcome or with the occurrence of adverse events will be selected for identification by mass spectrometry or equivalent technology.


Refer to Section 14.2, Appendix 2 for details on PGx research for this study.

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7. INVESTIGATIONAL PRODUCT(S)

7.1. Description of Investigational Product

7.1.1. Lapatinib

Lapatinib ditosylate monohydrate tablets, 250 mg, are oval, biconvex, orange, film-coated tablets that are debossed on one side with FG HLS. Tablets contain 410 mg of GW572016 ditosylate monohydrate, equivalent to 250 mg GW572015 free base per tablet. Refer to the Investigator’s Brochure (IB) for information regarding the physical and chemical properties of the drug substance and list of excipients.

7.1.2. Placebo

Placebo tablets will be identical to active lapatinib oval, biconvex, orange, film-coated that are debossed on one side with FG HLS. The tablets contain microcrystalline cellulose and lactose.

7.2. Dosage and Administration

7.2.1. Lapatinib or Placebo

Study drug (lapatinib or placebo) will be dispensed on Day 1 after confirmation of all eligibility criteria and completion of all screening assessments and review of all results. Each subject will receive study drug in a 3-month supply that includes six bottles containing 90 tablets in each bottle. The subjects are to return to the site approximately every 3 months for re-supply of study drug.

Subjects will be carefully instructed by study staff as to how to take study drug. A daily dose of study drug (lapatinib or placebo) is six tablets (1500mg of lapatinib) taken approximately at the same time each day. Subjects will be instructed to take study drug either 1 hour (or more) before a meal or 1 hour (or more) after a meal (for example, 1 hour before or after breakfast each day). If a subject misses the prescribed daily dose of study drug and it is more than 6 hours from the time the study drug was scheduled to be taken, the subject should not take that daily dose and resume taking the daily dose at the next scheduled time (that is, the following day).

A record of study drug administered to each subject must be maintained in the source documents (refer to Section 7.9 for details on compliance).

NOTE: Study drug should NOT be taken with grapefruit or grapefruit juice. Grapefruit and grapefruit juice are not permitted for the duration of the study.

If a subject vomits after administration of study drug, she should be instructed not to retake the dose. Subjects should take the next scheduled dose. If vomiting persists, then the subject should contact the investigator.

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7.2.2. Dose Adjustments

Subjects will be treated for a maximum of 1 year (52 weeks) or until disease recurrence or withdrawal from study treatment due to unacceptable toxicity or consent withdrawal. At each 3-month course of therapy, subjects will be evaluated for evidence of study drug-related (lapatinib or placebo) toxicity. Results of laboratory assessments should be reviewed as soon as they are available following each 3-monthly visit. If study drug-related toxicity is observed or suspected, the subject may need to be contacted or return to the site for further evaluation or modification to study drug administration.

Throughout the study, the criteria in Table 7 will be used to modify the study drug administration according to toxicity. Figure 2 in Section 7.2.2.1 provides specific details on criteria used to modify the study drug administration according to asymptomatic or mildly symptomatic cardiac events. Section 7.2.2.2 provides specific details on criteria used to modify the study drug administration according to liver chemistry results and follow up criteria for a liver-related event.

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Table 7 Criteria for Study Drug Administration

Toxicity (Graded According to NCI CTCAE) Action to be taken1 Non-hematologic2 CTCAE Grade 1 or 2 (except Grade 1 or 2 diarrhea with complicating features)

Continue study drug • IF prolonged duration (≥2 weeks) of Grade 2 occurs which affects the

subject’s quality of life, reduce study drug to 5 tablets (equivalent to 1250mg QD active drug)

Refer to Supportive Care Guidelines in the SRM for uncomplicated diarrhea and skin toxicities. Refer to Figure 2 for asymptomatic or mildly symptomatic cardiac event

CTCAE Grade 3 or 4 toxicity (except interstitial pneumonitis, Grade 4 rash, or left ventricular cardiac dysfunction) or CTCAE Grade 1 or 2 diarrhea with complicating feature

• CTCAE Grade 3 or 4 interstitial pneumonitis • CTCAE Grade 4 rash manifested as toxic epidermal

necrolysis (i.e., Stevens Johnson’s Syndrome, etc) • CTCAE Grade 3 or 4 left ventricular cardiac dysfunction

(symptomatic)

Delay study drug until resolution to Grade 0 or 1 (up to 2 weeks) • IF recurrence of toxicity (after delaying study drug) occurs, then reduce

to 5 tablets (equivalent to 1250mg QD active drug). • IF toxicity does not resolve to ≤ Grade 2 (within 2 weeks from last

administration), consult with Medical Monitor before continuing therapy.

Discontinue study therapy if Grade 3/4 interstitial pneumonitis or cardiac dysfunction, or Grade 4 Stevens Johnson’s Syndrome. Treatment of these CTCAEs is indicated as clinically appropriate. Refer to Supportive Care Guidelines in the SRM for diarrhea and skin toxicities

Hematologic absolute neutrophil count <1.0 × 109/L platelets <50 × 109/L hemoglobin <7.0 g/dL (after transfusion if needed)

Delay study drug until resolved to CTCAE Grade 0 or 1 (up to 2 weeks)

1. refer to Section 7.2.2.3 and Section 7.2.2.4 for details on dose delays and dose reductions, respectively; 2. includes chemistry-related toxicity and all other non-laboratory toxicity; Abbreviations: CTCAE = common terminology criteria for adverse events; QD = once daily; SRM = Study Reference Manual. [National Cancer Institute, 2005]

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7.2.2.1. Criteria for Evaluating Asymptomatic or Mildly Symptomatic Cardiac Events

Subjects who experience an asymptomatic or mildly symptomatic decrease in LVEF from baseline must be treated according to the algorithm depicted in Figure 2.

NOTE: Subjects with NYHA Class III or IV CHF must permanently discontinue study drug upon diagnosis and seek cardiology consultation.

Figure 2 Algorithm for continuation or discontinuation of study drug based on interval LVEF assessments

LVEF drop

HOLD study drug and

REPEAT LVEF in 3 weeks

LVEF <50 %

LVEF drop ≤20% points

LVEF drop >20% points


LVEF drop≤10% points

CONTINUE study drugand

REPEAT LVEF as per protocol1


REPEAT LVEFin 3 weeks2

LVEF <50% and


LVEF <50%and


DISCONTINUEstudy drug3

RESUME study drug

and REPEAT LVEF

in 3 weeks

LVEF ≥50%

LVEF ≥50% and

LVEF drop >10%or ≤10% points

REDUCE study drug to

4 tablets and


1. Cardiac evaluation by echocardiogram or MUGA should recommence at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1.

2. If upon repeat LVEF evaluation the LVEF drop and LVEF value are the same as the previous evaluation, then call the Medical Monitor.

3. Cardiac evaluations by echocardiogram or MUGA must be performed every 4 weeks for at least 16 weeks or until resolution.

If a secondary cardiac event is confirmed, then study drug will be permanently discontinued (shaded pathway in Figure 2). If following a dose reduction for a cardiac event, a subject experiences an absolute decrease in LVEF of more than 10 percentage points from baseline AND to an LVEF value below 50%, then study drug will be permanently discontinued. In subjects who permanently discontinue study drug, cardiac evaluations must be performed every 4 weeks for at least 16 weeks or until resolution.

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7.2.2.2. Liver Chemistry Stopping Rules and Follow Up Criteria

7.2.2.2.1. Liver Chemistry Stopping Rules

Liver chemistry stopping rules and follow up criteria have been designed to assure subject safety and to evaluate liver event etiologies. All subjects who meet liver chemistry criteria requiring permanent discontinuation of investigational product must continue to be followed for the study assessments and procedures as defined in Section 6 and at the time points indicated in the Time & Events Table in Section 14.1 Appendix 1.

If a subject experiences any of the following:

• ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation required*);

*NOTE: bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the actions detailed below must still be performed.

• ALT ≥5 × ULN; • ALT >3× ULN with signs or symptoms of hepatitis or hypersensitivity (the

appearance or worsening of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or eosinophilia);

• ALT >3 × ULN persisting for ≥4 weeks (subjects with ALT >3 × ULN should be monitored weekly for 4 weeks to determine if ALT elevation persists);

• ALT >3 × ULN and unable to undergo weekly monitoring.

then the following actions must be taken:

• immediately and permanently discontinue investigational product;

• for subjects who have ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation required*), promptly report the event as SAE to GSK within 24 hours of learning its occurrence (refer to Section 10.5 for guidance on prompt reporting to GSK);

• complete the SAE data collection tool for all other subjects only if the event meets the criteria for an SAE;

• complete the liver event eCRF and the liver imaging and/or liver biopsy eCRFs, if these tests are performed;

• monitor every week until liver chemistries resolve, stabilize, or return to within baseline values

• do not re-challenge with investigational product.

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If a subject experiences ALT >3 × ULN but <5 × ULN and total bilirubin ≤2 × ULN, without signs or symptoms of hepatitis or hypersensitivity, and who can be monitored weekly, then the following actions should be taken:

• continue investigational product;

• monitor weekly until liver chemistries resolve, stabilize, or return to within baseline, then monitor liver chemistries as per protocol assessment schedule;

• if at any time this subject meets any of the aforementioned liver chemistry stopping rules, then proceed as described above;

7.2.2.2.2. Liver Chemistry Follow Up Criteria

For all subjects who meet any of the liver chemistry stopping rules, make every attempt to carry out the liver event follow up assessments described below:

• Viral hepatitis serology including:

• Hepatitis A IgM antibody;

• Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM);

• Hepatitis C RNA;

• Cytomegalovirus IgM antibody;

• Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain heterophile antibody or monospot testing);

• Hepatitis E IgM antibody (if subject resides or has travelled outside USA or Canada in past 3 months);

• Serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH);

• Complete blood count with differential to assess eosinophilia;

• Record the appearance or worsening of clinical symptoms of hepatitis, or hypersensitivity, fatigue, decreased appetite, nausea, vomiting, abdominal pain, jaundice, fever, or rash as relevant on the AE eCRF;

• Record use of concomitant medications, acetaminophen, herbal remedies, other over the counter medications, or putative hepatotoxins, on the concomitant medications eCRF;

• Record alcohol use on the liver event alcohol intake eCRF;

The following assessments are suggested:

• specialist or hepatology consultation;

• anti-nuclear antibody, anti-smooth muscle antibody, and Type 1 anti-liver kidney microsomal antibodies;

• liver imaging and/or liver biopsy to evaluate liver disease;

• additional tests (e.g., pharmacokinetics) may be required.

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Figure 3 presents a liver safety algorithm detailing stopping rules and follow up criteria.

Figure 3 Algorithm for Liver Chemistry Stopping Rules and Follow up Criteria

ALT >3 × ULN

Bilirubina >2 × ULN (>35% direct) ALT ≥5 × ULN

signs & symptomsb

of hepatitis orhypersensitivity

Able to monitor liver chemistries

weekly

Continue IP; monitor liver

chemistries weekly for 4 weeks

ALT >3 × ULN persistsfor ≥4 weeks

Continue IP; monitor weekly until

liver chemistries resolve, stabilize, or return to baselinec

• immediately & permanently discontinue investigational product;• complete the SAE eCRF (if applicable); • perform liver event follow up assessments (serologies, etc, as noted in Section 7.2.2.2.2);• complete the liver event CRF, liver imaging and/or biopsy eCRFs, if these tests were done• monitor weekly until liver chemistries resolve, stabilize, or return to baseline;• do NOT re-challenge with investigational product

Report as SAE to GSK within 24 hours

Yes

Yes

No No

Yes Yes No

No

Yes Yes

No

Yes

Yes

IF:

a. bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the event should still be reported as an SAE and actions taken as described

b. the appearance or worsening of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or eosinophilia

c. once liver chemistries resolve, stabilize, or return to baseline, then continue monitoring per the protocol assessment schedule

7.2.2.3. Dose Delays

Administration of study drug may be delayed (according to criteria in Table 7) up to 2 weeks to allow for resolution of toxicity except in the event of NCI CTCAE Grade 3 or 4 left ventricular cardiac dysfunction, NCI CTCAE Grade 3 or 4 interstitial pneumonitis, or NCI CTCAE Grade 4 rash manifested as toxic epidermal necrolysis [National Cancer Institute, 2005]. If treatment is delayed for reasons other than toxicity (i.e., unplanned travel or vacation, or lack of transportation to the site) and the subject has insufficient study drug available, the subject should resume the usual dosing schedule once drug supply has been made available. However, if the subject has been off therapy for more than 2 weeks, the investigator must consult the GSK Medical Monitor prior to continuing therapy.

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7.2.2.4. Dose Reductions

Dose reduction for drug-related toxicity is permitted (according to criteria in Table 7). Dose escalation is not permitted; therefore, subjects should not be re-challenged to a higher dose level.

7.3. Dose Rationale

The dose of lapatinib to be tested in this study is 1500 mg QD and was selected based upon the following criteria:

• Cell-based assays demonstrate that the lapatinib concentration required to inhibit proliferation of either ErbB1 or ErbB2 over-expressing tumor cell lines by 90% (IC90) ranged from 520ng/mL to 1313ng/mL, depending upon the cell line. These concentrations were associated with 90% inhibition of tumor cell proliferation and comparable inhibition of ErbB1 or ErbB2 receptor tyrosine phosphorylation.

• In the initial Phase I patient study (EGF10003), lapatinib doses of 1200 mg and 1600 mg QD were well tolerated with only Grade 1/2 diarrhea and skin rash reported.

• Initial biopsies of skin, which expresses ErbB1 in the epidermis, show that doses below 1200 mg QD inhibit ErbB tyrosine autophosphorylation, indicating that 1500 mg QD is within in the biologically active dose range.

• Preliminary analysis of EGF10004 indicates that doses of 1200 mg QD produced biological activity against growth and survival pathways in tumor biopsies. Data showed a plateau of effects on biomarkers (pErbB1, pErbB2, pAKT, and pERK) between doses 1200 mg and 1500 mg daily. No maximum tolerated dose was reached at the maximum dose given (1800 mg/day). Therefore, to ensure that patients received the optimum effect from lapatinib, the dose of lapatinib was increased from 1250 to 1500 mg/day, with the expectation that this change was unlikely to affect the safety profile.

• Pharmacokinetic data in patients receiving lapatinib doses up to 1800 mg QD indicate that QD dosing results in 1.5- to 2-fold accumulation and 3-fold fluctuation between peak and trough plasma concentrations at steady state. Based on these data, 1500 mg QD is likely to produce a steady-state plasma concentration profile with peaks that are above, and troughs that are below these in vitro IC90. Although steady-state trough concentrations at this dose may not exceed these in vitro IC90, data from animal xenografts indicate that intra-tumoral concentration exceeds and lags behind plasma concentration. Therefore, declining plasma concentrations in patients may not preclude continuous exposure in tumors with QD dosing.

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The duration of lapatinib treatment in this study is a maximum of 12 months. Although the duration of lapatinib treatment in the adjuvant setting has not been previously evaluated, preliminary results from recent adjuvant trials showed that 12 months of ErbB2-directed therapy significantly reduced the risk of disease recurrence [Romond, 2005] [Piccart-Gebhart, 2005]. The length of treatment of lapatinib was partly based on clinical safety data to date indicating that adverse events associated with lapatinib have been generally mild to moderate in severity, and include nausea, diarrhea, fatigue, rash (some rashes look like acne), and weight loss. Thus, the 12-month treatment duration in this trial appears reasonable. Several studies in which patient exposure to lapatinib is >49 weeks are ongoing and GSK continues to monitor these trials.

7.4. Blinding

Only in the case of an emergency, when knowledge of the investigational product is essential for the clinical management or welfare of the subject, the investigator may unblind a subject’s treatment assignment. The investigator will, whenever possible, discuss options with the Medical Monitor, on-call physician, or appropriate GSK study personnel before unblinding. If the blind is broken for any reason and the investigator is unable to contact GSK prior to unblinding, the investigator must notify GSK as soon as possible following the unblinding incident without revealing the subject’s study treatment assignment, unless the information is important to the safety of subjects remaining in the study. In addition, the investigator will record the date and reason for revealing the blinded treatment assignment for that subject in the appropriate data collection tool as defined in Section 12.8.

If a SAE (as defined in Section 10.2) is reported to GSK, Global Clinical Safety and Pharmacovigilance (GCSP) staff may unblind the treatment assignment for the individual subject. If an expedited regulatory report to one or more regulatory agencies is required, the report will identify the subject’s treatment assignment. When applicable, a copy of the regulatory report may be sent to investigators in accordance with relevant regulations, GSK policy, or both.

7.5. Treatment Assignment

Subjects will be assigned to study treatment in accordance with the randomization schedule. Subjects will be identified by a unique subject number that will remain constant for the duration of the study. Investigators or designated staff will telephone the GSK interactive voice response (IVR) system called Registration And Medication Ordering System (RAMOS) to register and record subject activity. To randomize a subject, the site staff will enter the subject number and the subject’s time from initial diagnosis, time from completion of primary adjuvant chemotherapy, hormone receptor status, and lymph node involvement (refer to Section 7.5.1) to obtain a randomization number and treatment group assignment. All calls to RAMOS are confirmed with a fax, which will be sent to the site on the completion of each call. Study-specific instructional worksheets will be provided for the use of the IVR system.

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NOTE: certain demographic characteristics (time interval from completion of primary adjuvant chemotherapy to randomization and time interval from initial diagnosis to randomization) will be monitored throughout the trial. To avoid an over-representation of any one subgroup in this heterogeneous population, MGH and GSK reserve the right to curtail accrual. The decision to suspend enrollment of certain over-represented subgroups will be made by the study Steering Committee and will be communicated to investigative centers directly and expediently in the form of a letter.

7.5.1. Stratification

Randomization will be stratified according to the following:

• time from initial diagnosis (≤4 years versus >4 years);

• hormone receptor status (ER and/or PgR positive versus ER and PgR negative);

• lymph node involvement (positive versus negative).

7.6. Packaging and Labeling

Lapatinib or placebo will be provided in high-density polyethylene (HDPE) bottles with a child-resistant closure, packaged with 90 tablets per bottle. Each bottle will be labeled with the protocol number, product description, dosing instructions, storage instructions, expiry date, storage instructions, inventory number, and the following 'Caution' statement: "Caution: New Drug Limited by Federal (or United States) law to investigational use. GlaxoSmithKline, Research Triangle Park, NC 27709 USA" or any other applicable regulatory statements. The contents of the label will be in accordance with all applicable regulatory requirements.

7.7. Handling and Storage

Investigational product must be dispensed or administered according to procedures described herein. Only subjects enrolled in the study may receive investigational product, in accordance with all applicable regulatory requirements. Only authorized site staff may supply or administer investigational product. All investigational products must be stored in a secure area with access limited to the investigator and authorized site staff and under physical conditions that are consistent with investigational product-specific requirements.

Investigational product should be stored at room temperature (up to 30°C) and protected from the light. Unopened bottles of investigational product are stable until the date indicated on the package label when stored at room temperature (up to 30°C) and protected from the light.

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7.8. Product Accountability

The investigator, institution, or the head of the medical institution (where applicable) is responsible for investigational product accountability, reconciliation, and record maintenance. In accordance with all applicable regulatory requirements, the investigator or the head of the medical institution (where applicable), or designated site staff (e.g., storage manager, where applicable) must maintain investigational product accountability records throughout the course of the study. The responsible person(s) will document the amount of investigational product received from and returned to GSK (when applicable), the amount supplied and/or administered to and returned by subjects, if applicable.

Unused study drug must be stored up to 30°C until inventoried. After completion of the study, all unused study medication will be inventoried and packaged for return shipment by the site, or where applicable, study medication will be destroyed locally at the site and not returned to GSK. Refer to the SRM for shipping information.

Copies of all forms, documenting drug receipt at the study site and returned to GSK, together with drug accountability records, will be retained according to the regulations governing record retention (refer to Section 12.5).

7.9. Assessment of Compliance

A record of the number of tablets dispensed to and returned by each subject must be documented in the Drug Dispensing Log for each subject. The estimate of percent compliance will be calculated as:

*number of days in visit interval = (date returned — date dispensed) +1 in visit interval.

The number of tablets prescribed per day will be calculated using the assigned dose from the IP form in the eCRFs. The expected number of tablets to be taken daily is 6 tablets (250mg each); however, any investigator-prescribed dose adjustments, such as, withdrawing study drug or reducing dose, will be taken into account. Refer to the Study Drug Management document in the SRM for details on these calculations.

NOTE: subjects who are instructed by the investigator to withdraw study drug (for example, due to an adverse event) will not be considered non-compliant. The number of days in this interval where study drug was withdrawn will be excluded from the compliance calculation (i.e., excluded from the number of days in the visit interval).

Compliance with dosing will be assessed through querying the subject during the site visits and the percent compliance will be documented in the source documents and recorded in the eCRF. The investigator’s judgment of compliance will be accepted. Subjects should be instructed to record any missed doses of investigational product.

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7.10. Treatment of Investigational Product Overdose

Subjects with suspected overdose should be monitored until investigational product can no longer be detected systemically (at least 5 half-lives). Follow-up physical examination with laboratory testing should be performed between 10 and 14 days after drug concentrations are undetectable and before the subject is discharged from the investigator’s care. Any AEs or SAEs that occur as a result of an overdose should be reported to the GSK Medical Monitor (refer to Section 10).

7.11. Occupational Safety

Investigational product is not expected to pose significant occupational safety risk to site staff under normal conditions of use and administration. A Material Safety Data Sheet (MSDS)/equivalent document describing occupational hazards and recommended handling precautions either will be provided to the investigator, where this is required by local laws, or is available upon request from GSK.

8. CONCOMITANT MEDICATIONS AND NON-DRUG THERAPIES

8.1. Permitted Medications

All concomitant medications taken during the study will be recorded in the eCRF with indication, dose information, and dates of administration.

The following will be recorded on the appropriate eCRF pages:

• A complete list of prescription and over-the-counter medications that have been taken within 4 weeks prior to the first dose of study drug.

• All concomitant medications (including herbal remedies) taken while subjects are receiving study drug.

Subjects should receive full supportive care during the study, including transfusion of blood and blood products, and treatment with antibiotics, antiemetics, antidiarrheals, and analgesics, as appropriate. Refer to SRM for supportive care guidelines for diarrhea and skin toxicities.

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8.2. Prohibited Medications

The following medications are prohibited from 3 weeks before the first dose of study drug through study drug discontinuation, unless otherwise noted:

• Anti-cancer therapy (other than investigational product and endocrine therapy, as defined in Inclusion Criterion #11; refer to Section 5.2.1);

• Investigational drugs are not permitted from 4 weeks (30 days) or 5 half-lives, whichever is longer, prior to the first dose and up through 30 days after the last dose of investigational product;

Retrospective analysis of pharmacokinetic data from Phase I clinical studies suggests that concomitant use of proton pump inhibitors and histamine H2-antagonists to elevate gastric pH does not significantly decrease lapatinib absorption. Prior to obtaining this information, prohibition of these agents was based on in vitro data demonstrating a significant decline in lapatinib solubility at pH values >4. Based on this new information, concomitant use of these agents appears unlikely to diminish systemic exposure to lapatinib.

Lapatinib is a substrate for CYP3A4. Inducers and inhibitors of CYP3A4 may alter the metabolism of lapatinib. The following list of CYP3A4 inducers and inhibitors are prohibited from screening through discontinuation from study. Additionally, medications that modify gastric pH are included in Table 8:

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Table 8 Prohibited Medications

Drug Class Agent Wash-out1 CYP3A4 Inducers Antibiotics all rifamycin class agents (e.g., rifampicin,

rifabutin, rifapentine) 14 days Anticonvulsants phenytoin, carbamazepine, barbiturates (e.g.,

phenobarbital) Antiretrovirals efavirenz, nevirapine Glucocorticoids (oral) cortisone (>50 mg), hydrocortisone (>40 mg),

prednisone (>10 mg), methylprednisolone (>8 mg), dexamethasone (>1.5 mg)2

Other St. John’s Wort, modafinil CYP3A4 Inhibitors Antibiotics clarithromycin, erythromycin, troleandomycin

7 days Antifungals itraconazole, ketoconazole, fluconazole (>150 mg daily), voriconazole

Antiretrovirals, Protease Inhibitors

delaviridine, nelfinavir, amprenavir, ritonavir, indinavir, saquinavir, lopinivir, atazanivir

Calcium channel blockers verapamil, diltiazem Antidepressants nefazodone, fluvoxamine GI Agents cimetidine, aprepitant Other grapefruit, grapefruit juice

amiodarone 6 months

Miscellaneous Antacids Mylanta, Maalox, Tums, Rennies 1 hour before and

after dosing Herbal supplements3 Ginkgo biloba, kava, grape seed, valerian,

ginseng, echinacea, evening primrose oil. 14 days

1. At the time of screening, if a patient is receiving any of the above listed medications/substances, the medication or substance must be discontinued (if clinically appropriate) for the period of time specified prior to administration of the first dose of study drug and throughout the study period in order for the patient to be eligible to participate in the study.

2. Glucocorticoid daily doses (oral) ≤ 1.5 mg dexamethasone (or equivalent) are allowed. Glucocorticoid conversions are provided in parentheses.

3. This list is not all-inclusive; therefore, for herbal supplements not listed, please contact the GSK Medical Monitor or Clinical Scientist.

NOTE: if future changes are made to the list of prohibited medications, a formal documentation will be created and stored with the study file. Any changes will be communicated to the investigative sites in the form of a letter.

8.3. Non-Drug Therapies

Concurrent surgery as cancer therapy and radiotherapy (unless initiated as adjuvant therapy for treatment of the initial diagnosis of invasive breast cancer) is prohibited during randomized therapy.

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9. SUBJECT COMPLETION AND WITHDRAWAL

9.1. Subject Completion

A subject will be considered as completing the study for data collection purposes to ensure adequate collection of survival information if:

• the subject is no longer receiving treatment with investigational product and has completed 10 years of follow-up;

OR

• the subject has died.

9.2. Subject Withdrawal

9.2.1. Subject Withdrawal from Study

A subject will be considered as withdrawing from the study if:

• the subject has permanently discontinued treatment with investigational product and is no longer being followed for the study assessments and procedures, including follow-up procedures.

A subject may voluntarily withdrawal from the study at any time. The investigator may also, at his/her discretion, withdrawal the subject from the study at any time.

The primary reason for withdrawal from study, as listed below, must be entered on the ‘Study Conclusion’ eCRF page:

• protocol violation (including non-compliance);

• lost to follow-up

• the subject withdraws consent from all study procedures;

• death

• termination of the study by the Sponsor

• investigator decision

If a subject withdraws or is withdrawn from the study for any reason, the investigator must make every effort to perform the procedures for early study withdrawal specified in the Time & Events Table in Section 14.1, Appendix 1.

If a subject who has consented to participate in PGx research withdraws from the clinical study for any reason other than lost to follow-up, the subject will be given the following options concerning the PGx sample if already collected:

• PGx research continues per the subject’s consent; or,

• Any remaining sample is destroyed.

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If a subject withdraws consent from the PGx research or requests sample destruction, the investigator must complete the appropriate documentation to request sample destruction within the timeframe specified by GSK and maintain the documentation in the site study records. In either case, GSK will only keep and study information collected/generated up to that point.

9.2.2. Subject Withdrawal from Study Drug

A subject will be considered as withdrawing from study drug if:

• the subject has completed the 12-month treatment period of study drug;

OR

• the subject has prematurely, but permanently, discontinued taking study drug.

The primary reason for withdrawal from study drug, as listed below, must be entered on the ‘Investigational Product Discontinuation’ eCRF page:

• completion of the 12-month treatment period with either lapatinib or placebo;

• AE (including intercurrent illness, unacceptable toxicity);

NOTE: Refer to details regarding liver chemistry stopping rules as specified in Section 7.2.2.2.1.

• diagnosis of disease recurrence (local, regional or distant) according to criteria defined in Section 6.3.1.1.1;

• diagnosis of second primary cancer (breast or non-breast) according to criteria defined in Section 6.3.1.1.2;

• death;

• protocol violation (including non-compliance);

• lost to follow-up;

• termination of the study by the Sponsor;

• the subject withdraws consent after being treated with study drug.

NOTE: if the subject has not withdrawn consent from all study procedures, required procedures, including follow-up procedures, must be performed in these subjects (refer to Time & Events Table in Section 14.1, Appendix 1);

When applicable, all subjects who withdraw from study drug must continue to be followed for the study assessments and procedures, including follow-up procedures, as defined in Section 6 and at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1. To ensure timely safety and efficacy assessments in patients who prematurely withdraw from study drug or complete the 12-month treatment period of study drug, the Early Study Withdrawal Visit/Month 12 Visit should occur on or as soon as possible after early discontinuation or completion of study drug day. Subjects who have disease recurrence may be asked to participate in additional research on

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biomarkers derived from a tumor tissue biopsy; participation is optional and refusal to participate will not lead to withdrawal from the clinical study.

If the reason for withdrawal from study drug results in withdrawal from the study (e.g., lost to follow-up, death), the ‘Study Discontinuation’ eCRF page, as mentioned in Section 9.2.1, must be completed and the reason must be consistent with that entered on the ‘Investigational Product Discontinuation’ eCRF page.

9.3. Treatment After the End of the Study

When the subject is withdrawn from all investigational products, the subject will be treated as determined by the attending physician.

9.4. Extension Study

At this time, an extension study is not planned.

9.5. Screen and Baseline Failures

A subject is considered to be a screen/baseline failure if the subject signs the ICF, but withdraws before receiving study treatment.

All potential subjects who are screened for enrollment in this study including screening/baseline failures will be listed on the Subject Screening Log/Identification List. Reasons for exclusion will be recorded for potential subjects who do not enter the study.

If a blood sample for PGx research has been collected and it is determined that the subject does not meet the inclusion and exclusion criteria for participation in the clinical study, then the investigator must complete the appropriate documentation to request sample destruction within 5 days and maintain the documentation in the site study records.

10. ADVERSE EVENTS (AE) AND SERIOUS ADVERSE EVENTS (SAE)

The investigator is responsible for the detection and documentation of events meeting the criteria and definition of an AE or SAE, as provided in this protocol. During the study when there is a safety evaluation, the investigator or site staff will be responsible for detecting, documenting and reporting AEs and SAEs, as detailed in both this section of the protocol and in the AE/SAE section of the SRM.

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10.1. Definition of an AE

Any untoward medical occurrence in a patient or clinical investigation subject, temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product.

NOTE: An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the use of a medicinal product. For marketed medicinal products, this also includes failure to produce expected benefits (i.e. lack of efficacy), abuse or misuse.

Symptomatic declines in LVEF that do not meet the criteria for a secondary cardiac endpoint (e.g. an absolute decrease in LVEF of ≤10 percentage points from baseline and to an LVEF value <50% OR an absolute decrease in LVEF of >10 percentage points from baseline and to an LVEF value of ≥50%) are not expected to be common. These events should be reported as AEs or SAEs, if applicable, as described below. Asymptomatic declines in LVEF that do not meet the criteria for ‘significant’, as defined in Section 6.2.3.1.2, do not qualify as a secondary cardiac endpoint and will not be reported as AEs.

10.2. Definition of a SAE

A serious adverse event is any untoward medical occurrence that, at any dose:

a. Results in death

b. Is life-threatening

NOTE: The term 'life-threatening' in the definition of 'serious' refers to an event in which the subject was at risk of death at the time of the event. It does not refer to an event, which hypothetically might have caused death, if it were more severe.

c. Requires hospitalization or prolongation of existing hospitalization

NOTE: In general, hospitalization signifies that the subject has been detained (usually involving at least an overnight stay) at the hospital or emergency ward for observation and/or treatment that would not have been appropriate in the physician’s office or out-patient setting. Complications that occur during hospitalization are AEs. If a complication prolongs hospitalization or fulfills any other serious criteria, the event is serious. When in doubt as to whether “hospitalization” occurred or was necessary, the AE should be considered serious.

Hospitalization for elective treatment of a pre-existing condition that did not worsen from baseline is not considered an AE.

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d. Results in disability/incapacity, or

NOTE: The term disability means a substantial disruption of a person’s ability to conduct normal life functions. This definition is not intended to include experiences of relatively minor medical significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life functions but do not constitute a substantial disruption.

e. Is a congenital anomaly/birth defect

f. Medical or scientific judgment should be exercised in deciding whether reporting is appropriate in other situations, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but may jeopardize the subject or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These should also be considered serious. Examples of such events are invasive or malignant cancers, intensive treatment in an emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization, or development of drug dependency or drug abuse.

Additional protocol-defined criteria

• All Grade 4 laboratory abnormalities.

Cardiovascular events have been seen in subjects taking other compounds that inhibit ErbB2 when used in combination with or following anthracyclines and interstitial pneumonitis has been reported in subjects taking compounds that inhibit ErbB1. As a precaution, the following will be reported as an SAE:

• Primary cardiac endpoints (severe symptomatic CHF and cardiac death).

NOTE: If a secondary cardiac endpoint fulfills any of the criteria for ‘seriousness’ (e.g. hospitalization), it must also be reported as an SAE.

• Any signs or symptoms of pneumonitis that are ≥ Grade 3 (NCI CTCAE) (defined as radiographic changes and requiring oxygen). Refer to NCI CTCAE grading of pneumonitis/pulmonary infiltrates [National Cancer Institute, 2005].

Hepatobiliary events have been seen in subjects taking lapatinib and other tyrosine kinase inhibitors. As a precaution, the following will be reported as an SAE:

• ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation required).

NOTE: bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the event should still be reported as an SAE.

Other hepatic events should be documented as an AE or an SAE as appropriate.

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10.2.1. Disease-Related Events and/or Disease-Related Outcomes Not Qualifying as SAEs

An event which is part of the natural course of the disease under study (i.e., disease recurrence) does not need to be reported as an SAE. Recurrence of the subject's disease will be recorded in the clinical assessments in the eCRF. However, if a recurrence of the underlying disease is greater than that which would normally be expected for the subject, or if the investigator considers that there was a causal relationship between study treatment or protocol design/procedures and the disease recurrence, then this must be reported as an SAE. Any new primary cancer must be reported as an SAE.

10.2.2. Clinical Laboratory Abnormalities and Other Abnormal Assessments as AEs and SAEs

Abnormal laboratory findings (e.g., clinical chemistry and hematology) or other abnormal assessments (e.g., X-rays and scans, etc.) that are judged by the investigator as clinically significant will be recorded as AEs or SAEs if they meet the definition of an AE or SAE, as defined in Section 10.1 and Section 10.2, respectively. Clinically significant abnormal laboratory findings or other abnormal assessments that are detected during the study or are present at baseline and significantly worsen following the start of the study will be reported as AEs or SAEs. However, clinically significant abnormal laboratory findings or other abnormal assessments that are associated with the disease being studied, unless judged by the investigator as more severe than expected for the subject’s condition, or that are present or detected at the start of the study and do not worsen, will not be reported as AEs or SAEs.

The investigator will exercise his or her medical and scientific judgment in deciding whether an abnormal laboratory finding or other abnormal assessment is clinically significant.

As defined in Section 10.2, all Grade 4 laboratory abnormalities will be reported as SAEs.

10.3. Lack of Efficacy

“Lack of efficacy” per se will not be reported as an AE. The signs and symptoms or clinical sequelae resulting from lack of efficacy will be reported if they fulfill the AE or SAE definition (including clarifications).

10.4. Time Period, and Frequency of Detecting AEs and SAEs

From the time a subject consents to participate in the study until she has completed the study (including any follow-up period), all SAEs assessed as related to study participation (e.g., protocol-mandated procedures, invasive tests, or change in existing therapy) or related to a GSK concomitant medication, will be reported promptly to GSK.

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All AEs and SAEs regardless of relationship to study drug will be collected from the first dose of study drug to 5 days after the last dose and recorded on the eCRF.

Serious adverse events brought to the attention of the investigator at any time after cessation of study drug and considered by the investigator to be related or possibly related to study drug must be reported to GSK if and when they occur.

Subjects will be monitored at each scheduled assessment at the site (approximately every 3 months during treatment), at any contact with the subject during the study, and at the withdrawal visit, for the occurrence of AEs/SAEs. The investigator or designee will inquire about the occurrence of AEs/SAEs at every visit/contact during the study and throughout the 5 days following cessation of treatment by asking the following standard questions:

1. How are you feeling?

2. Have you had any (other) medical problems since your last visit?

3. Have you taken any new medications since your last visit/assessment?

10.5. Prompt Reporting of SAEs to GSK

Serious adverse events, pregnancies, and liver function abnormalities meeting pre-defined stopping rules will be reported promptly to GSK as described in the following table once the investigator determines that the event meets the protocol definition of an SAE.

Table 9 Timeframes for Submitting SAE and Pregnancy Reports to GSK

Initial Reports Follow-up Information on a Previous Report

Type of SAE Time Frame Documents Time Frame Documents All SAEs 24 hours "SAE" data

collection tool 24 hours Updated "SAE"

data collection tool

Pregnancy 2 weeks Pregnancy Notification Form

2 weeks Pregnancy Follow up Form

Liver Chemistry

Abnormalities:

ALT >3 × ULN and bilirubina

>2 × ULN (35% direct)

24 hours Liver Event and Liver Imaging and/or Biopsy

eCRFs, if applicable

24 hours Updated Liver Event eCRF

Abbreviations: GSK = GlaxoSmithKline; SAE = serious adverse events a. bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets

the criterion of total bilirubin >2.0 × ULN, then the event should still be promptly reported as defined

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10.6. AE and SAE Documentation and Follow-up Procedures

The investigator will review and adhere to the following procedures, which are outlined in detail in the AE/SAE section of the SRM:

• Method of Detecting AEs and SAEs

• Recording of AEs and SAEs

• Evaluating of AEs and SAEs

• Completion and Transmission of SAE Reports to GSK

• Follow-up of AEs and SAEs

• Post-study AEs and SAEs

• Reporting new SAEs or updated SAE data after the electronic data collection tool has been taken off line.

• Regulatory Reporting Requirements for SAEs

11. DATA ANALYSIS AND STATISTICAL CONSIDERATIONS

11.1. Hypotheses

The study is designed to provide evidence to support the null hypothesis H0: λ=1 or to reject it in favour of the alternative hypothesis HA: λ<1, where λ is the hazard ratio for disease-free survival (DFS): lapatinib/placebo. In particular, the study will have 80% power to detect a 23% decrease in the hazard for DFS in the lapatinib arm, i.e. λ = 0.769. Under the assumption of exponential distributions for DFS, this is equivalent to a 30% increase in median DFS in subjects who receive lapatinib (112.7 months) compared with subjects who receive placebo (86.7 months) [Romond, 2005].

11.2. Study Design Considerations

11.2.1. Sample Size Assumptions

East-3 software was used to determine a group sequential design with suitable statistical properties [Mehta, 2004]. The following assumptions were made in the estimation of the required sample size:

• there will be a maximum of one interim analysis and one final analysis as described in Section 11.3.3;

• exponential distributions of time to disease recurrence (including the occurrence of another cancer or death);

• median times to disease recurrence of 112.7 months and 86.7 months in the lapatinib and placebo arms, respectively (i.e., a hazard ratio of 0.769) [Romond, 2005];

• 1:1 randomization scheme, but ignoring stratification (refer to Section 7.5.1);

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• a 2.5% risk of erroneously claiming superiority of lapatinib in the presence of no true underlying difference (one-sided Type I error);

• an 80% chance of successfully detecting a 30% increase in median DFS in subjects who receive lapatinib;

• average accrual rate of 125 subjects per month over 24 months (23 months and one additional month to allow for 4.2% withdrawals without prior disease recurrence).

A maximum of 463 subjects with disease recurrence will be required. To achieve this number, an estimated total of 3000 (2875+125) subjects would need to be enrolled, leading to an estimated maximum study duration of 37 months.

11.2.2. Sample Size Sensitivity

Table 10 shows, for various hazard ratios for DFS, the power to detect superior survival in the lapatinib arm (1-sided p ≤ 0.025) at the interim analysis and overall (at either the interim or by the final analysis of DFS).

Table 10 Power to Detect Superiority of Lapatinib Versus Placebo Disease-Free Survival

Hazard Ratio Power to Detect Superiority of Lapatinib, % Lapatinib/Placebo Interim Analysis Overall

1.00 0.001 2.5 0.80 9 66 0.769 16 80 0.70 43 97 0.67 60 99

A key secondary endpoint will be overall survival. Table 11 shows, for various hazard ratios for overall survival, the power to detect superior survival in the lapatinib arm (1-sided p ≤ 0.025) at the estimated time of the final analysis of DFS (37 months) and at 5 years.

NOTE: the assumed annual mortality rate (hazard rate) in the placebo arm was 0.047 [Romond, 2005].

Table 11 Power to Detect Superiority of Lapatinib Versus Placebo Overall Survival

Hazard Ratio Power to Detect Superiority of Lapatinib, % Lapatinib/Placebo Final Analysis (37 months) 5 years

0.80 41 65 0.75 59 85 0.67 84 98.1 0.50 99.7 >99.99

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11.2.3. Sample Size Re-estimation

Sample size re-estimation is not anticipated. However, if the rate of accumulation of events for the primary endpoint in the combined groups is unexpectedly high or low, with due allowance for rates of accrual and premature loss to follow-up, then the IDMC will be asked to advise on an appropriate course of action.

11.3. Data Analysis Considerations

11.3.1. Analysis Populations

The Intent-to-Treat (ITT) population will comprise all randomized subjects who receive at least one dose of randomized therapy (lapatinib or placebo), and will be used for the analysis of efficacy data.

The Safety population will comprise all randomized subjects who receive at least one dose of randomized therapy, and will be based on the actual treatment received if this differs from that to which the subject was randomized. This population will be used for the analysis of safety data.

The Per-Protocol (PP) population will comprise all randomized and treated subjects who comply closely with the protocol.

Serious protocol violations that would exclude subjects from the PP population will be defined and documented in the Reporting and Analysis Plan (RAP) prior to the release of the database. The PP population will be used to provide a supportive analysis of DFS only.

11.3.2. Treatment Comparisons

11.3.2.1. Primary Comparisons of Interest

The single treatment comparison will be between lapatinib and placebo. Unless otherwise stated below, all comparisons will be performed using the ITT population (refer to Section 11.3.1).

11.3.3. Interim Analysis

A maximum of two analyses (an interim analysis and a final analysis) of DFS will be performed. The interim analysis will occur when two-thirds of the total number of required events have occurred (i.e., at 309 events). The final analysis will take place when 463 events have occurred.

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The interim analysis is estimated to occur after about 28 months from the time the first subject is enrolled. A Haybittle-Peto stopping boundary with a one-sided 2.5% significance level will be used to reject H0 (i.e., support for superior efficacy in the lapatinib arm) [Mehta, 2005]. This boundary permits specification of the interim stopping boundary based on a pre-specified p-value, while adjusting the final p-value requirement to satisfy the overall alpha of 0.025 (one-sided). Superiority will be declared for DFS if the log-rank test results in p ≤0.0005 (one-sided). Using a one-sided Type I error, a nominal alpha of 0.0005 will be ‘spent’ at the interim analysis.

An analysis of overall survival data will be performed at the time of the interim analysis. For the IDMC committee to recommend early termination of the trial due to superior efficacy, it would be necessary for there to be a strong trend in survival in addition to having met the stopping criteria for superiority of DFS.

Futility will additionally be assessed at the interim analysis. The 95% confidence interval (CI) will be calculated for the hazard ratio (HR) (Lapatinib/Placebo) for DFS. If the lower boundary of the 95% CI for the HR for DFS is ≥0.885 (the mid-point between 0.769 and 1), then futility of lapatinib will be indicated. The IDMC may consider stopping the study if this criterion is met at the interim analysis.

Safety reviews will take place at 6 monthly intervals, from the initiation of the study. Overall survival (OS) data will be supplied at each 6 monthly safety review, (once there are sufficient deaths to perform this analysis.) If the OS data indicate highly significant evidence for inferiority of Lapatinib, then the IDMC may recommend early termination for the study. However, no specific stopping rule for safety will be defined.

To preserve the integrity of the study blind, the results of the interim analysis will only be known to the IDMC, and any recommendation to terminate the trial would not be based solely on statistical grounds. The conclusions of the IDMC will be communicated to senior management of GSK and, in the event of a recommendation to halt the trial early, to the appropriate regulatory agencies. Refer to Section 12.9 for further details on the IDMC.

11.3.4. Key Elements of Analysis Plan

11.3.4.1. Withdrawal

Subjects who are withdrawn prematurely from investigational product, but who are not withdrawn from the study at the same time, will be included in all analyses regardless of the duration of treatment.

All subjects withdrawn from the study will be included in analyses up to the time of withdrawal.

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11.3.4.2. Missing Data

As the period of treatment for any subject will be dependent on its efficacy and toxicity, the duration of follow-up will vary between subjects. Consequently, there will be no imputation for missing data. Where appropriate, available data will be summarized over specified intervals (e.g., from randomization until withdrawal from the study) using suitable summary statistics. Details will be given in the RAP.

For time-to-event endpoints, either the date of last known contact or the date of last radiological assessment will be used for those subjects who have not reached the event at the time of the analysis; such subjects will be considered censored in the analysis. This is described for each endpoint in the appropriate section and will be fully documented in the RAP.

11.3.4.3. Derived and Transformed Data

Details of the determination of recurrence of disease (e.g., local, regional and distant) and second primary cancer are given in Section 6.3.1.1.

11.3.4.4. Other Issues

Significance tests will be stratified by:

• time from initial diagnosis (≤4 years versus >4 years);

• hormone receptor status (ER and/or PgR positive versus ER and PgR negative);

• lymph node involvement (positive versus negative).

This will result in a total of 8 strata.

As randomization is not pre-stratified by study centre, this factor will not be included as a stratification variable in analyses based on randomization-based methodology. However, clusters of study centres based on geographical region or country will be considered as potential covariates in model-based analyses.

A summary and listing of protocol violations will be provided.

Demographic and baseline characteristics will be summarized.

Any deviations from, or additions to, the original analysis plan described in this protocol will be documented in the RAP.

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11.3.5. Efficacy Analyses

11.3.5.1. Primary Efficacy Analysis

The primary efficacy analysis will be based on DFS defined as the interval between the date of randomization and the date of objective disease recurrence, a second primary cancer, or death from any cause.

The date of the event will be defined as the earliest date of the occurrence of any of the following events:






• other second primary cancer (excluding squamous or basal cell carcinoma of the skin, melanoma in situ, carcinoma in situ of the cervix, or lobular carcinoma in situ of the breast)

• death from any cause without prior event (recurrence of breast cancer or second primary cancer)

Refer to Section 3.1 for full details.

Subjects who start any additional anti-cancer adjuvant therapy prior to recurrence of their disease will be censored on the date of their last assessment preceding such therapy.

The DFS times will be summarized using Kaplan Meier survival curves, from which the median times to disease recurrence will be calculated, along with 25% and 75% quartiles.

Treatment arms will be compared using a stratified log-rank test. An estimate of the treatment hazard ratio based on the log-rank test will be provided together with a corresponding 95% confidence interval.

The primary population for this analysis will be the ITT population, but the PP population will be used additionally for this primary analysis.

At the time of the final analysis only, Cox regression models will be fitted to the data including as a minimum, covariates for treatment, time from initial diagnosis (≤4 years versus >4 years), hormone receptor status (ER and/or PgR positive versus ER and PgR negative) and lymph node involvement (positive versus negative). Other factors predictive of time to disease recurrence will be included in the models as appropriate. Hazard ratios and associated 95% confidence limits and p-values for each factor will be presented. Further details will be described in the RAP.

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11.3.5.2. Secondary Analyses

From a formal inferential perspective, the Type I error will be fully allocated to the analysis of the primary endpoint of DFS. Thus the analyses of secondary endpoints will serve to support the analysis of DFS and will not provide the basis for formal statistical inference in their own right.

11.3.5.2.1. Percentages of Disease-Free Subjects: Time Point Estimates

The percentages of surviving subjects who are recurrence free at 6-month intervals from the time of randomization will be estimated from the Kaplan-Meier curves. This will include at a minimum the following time points: 6 months, 1 year, 18 months and 2 years. Approximate 95% confidence limits will be calculated, based on Greenwood's formula for the standard error of the Kaplan-Meier estimate.

11.3.5.2.2. Overall survival

Overall survival will be defined as the time from randomization until death due to any cause. For subjects who do not die, time to death will be censored at the time of last contact.

Overall survival will be analyzed at the times of the interim and final analyses of DFS, and at subsequent times, as determined by the IDMC, during the follow-up period.

11.3.5.2.3. Other Endpoints

The following time-to-event endpoints will be analyzed, recognizing that they are subject to the influence of competing risks:

• recurrence-free survival which includes the following events:






• distant recurrence-free survival which includes the following events:


• CNS recurrence-free survival Additionally, the rate of CNS recurrence will be summarized and analyzed. Full details of the analyses of secondary endpoints will be documented in the RAP.

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11.3.6. Safety Analyses

The Safety population will be used for the primary analysis of safety data. Complete details of the safety analyses below will be provided in the RAP.

Safety summaries will include all adverse events, serious adverse events, cardiac and laboratory data as described in the following sections.

11.3.6.1. Extent of Exposure

The numbers of subjects administered investigational product will be summarized according to the duration of therapy.

11.3.6.2. Adverse Events

Adverse events will be coded using the standard GSK Medical Dictionary for Regulatory Activities (MedDRA) dictionary, and grouped by system organ class. Events will be summarized by frequency and proportion of total subjects, by system organ class and preferred term. Separate summaries will be given for all AEs, for drug-related AEs, for serious AEs, and for AEs leading to withdrawal from the study.

The incidence of deaths will also be reported.

11.3.6.3. Clinical Laboratory Evaluations

Hematology and clinical chemistry data will be summarized at each scheduled assessment and presented by NCI CTCAE toxicity grade (Version 3.0) [National Cancer Institute, 2005]. The prevalence of values lying outside the reference range will also be presented.

11.3.6.4. Other Safety Measures

The results of scheduled assessments of body weight, vital signs, 12-lead ECG, echocardiogram (or MUGA scan), and ECOG performance status will be summarized. Details will be provided in the RAP.

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11.3.7. Health Outcomes Analyses

Health-related quality of life will be assessed through subject self-completion of the SF-36, a general health related quality of life metric (refer to Section 14.6, Appendix 6 for health survey). The SF-36 produces an eight scale profile [physical function, role limitations due to physical problems (role physical), bodily pain, general health perceptions (general health), vitality, social function, role limitations due to emotional problems (role emotional), and mental health] and two summary indexes for physical and mental health. The SF-36 will be completed at baseline (prior to administration of first dose of study drug) and prior to any other study procedures, including physician interaction. During the study treatment period, the SF-36 will be completed every 6 months (i.e., at Month 6 and Month 12). After withdrawal from study drug, the SF-36 will be completed every 6 months for 24 months.

All scoring of the SF-36 will be conducted per guidelines provided in the latest version of the test manual. Scores for each of the eight sub-scales, as well as the two summary indexes for physical and mental health, will be calculated on a 0-100 scale. Descriptive statistics for each of the eight subscale scores and two summary index scores will be calculated at baseline and Month 6. Score change between baseline and follow-up assessments will be calculated to account for possible differences in sub-scale or summary index score between treatment groups at baseline. The scores over different subgroups will also be presented by withdrawal or termination status, or other stratifying factors, as appropriate. Sub-scale and summary index scores change from baseline will be compared between lapatinib and placebo to test for significant statistical differences using ANCOVA, adjusting for baseline sub-scale or summary index score, dose, and country.

Data from the SF-36 will be scored according to recommendations by the authors of the instrument. Item scores will be recoded so that higher scores will correspond to better health status. The majority of items are originally coded in this manner. For certain items, the lowest scores indicate the best health status and the response to these questions will be recoded in the reverse order. The following items will require reverse coding: 1, 2, 6, 7, 8, 9d, 9e, 11b and 11d. Recoded scores will be transformed to a scale of 0-100. To transform the scores, recoded items will be summed to a raw score. The lowest possible score (the sum of the minimum scores for each item) will be subtracted from the raw score. The number will be divided by the range (highest possible score minus lowest possible score) and multiplied by 100. The recoded transformed scale scores (hereafter referred to as scores), and changes from baseline, will be summarized by visit. In all analyses requiring imputation of missing values, a last observation carried forward (LOCF) imputation strategy will be employed; alternately mixed models with select covariance structure assumptions will be used to eliminate imputation. Any subject failing to complete the baseline assessment will be precluded from quality of life assessment using the SF36.

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11.3.8. Biomarker(s) Analyses

Biomarkers derived from protein expression in the tumor will be tested retrospectively from archived tumor tissue obtained at the time of diagnosis. This may include the 4 epidermal growth factor receptor family members (ErbB1, ErbB2, ErbB3, and ErbB4), AKT, MAPK, and potentially other biomarkers that are downstream of ErbB1 and ErbB2 receptors. In addition, biomarkers derived from the archived tumor tissue sample will be compared with the biomarkers derived from the tumor tissue biopsy taken from the site of disease recurrence.

Differences in proteome profiles that can be correlated with other measures of response to lapatinib treatment will be used to identify potential novel candidate biomarkers/profiles of response. Differences that can be correlated with the occurrence of specific adverse events may be used in the future to predict which patients are more likely to have those events. Comparative examination of pre-dosing (day of screening) proteome profiles will be used to uncover novel candidate biomarkers/profiles which may be used to predict lapatinib response. Comparative examination of at-relapse proteome profiles in conjunction with pre-dosing profiles may yield novel candidate biomarkers/profiles which relate to mechanisms of disease recurrence.

Plasma protein studies will be performed by 2-D gel separation or an alternative fractionation method. Proprietary algorithms will be used to identify individual proteins exhibiting statistically acceptable changes in their level between samples, which appear to be associated with treatment outcome. These differentially expressed proteins will be selected for identification by mass spectrometry or equivalent technology. Alternatively, plasma samples may be used to validate hypotheses generated from current on-going studies of lapatinib.

11.3.9. Tumor Genetic Analyses

Direct sequencing of target-related and genes (such as, PI3K and PTEN) will be performed from archived paraffin-embedded tissue obtained at the time of diagnosis. In addition, unbiased genome-wide analyses of tumor-specific genetic changes (for example, using array technology) may also be performed. Correlating such profiles with clinical outcome and response to drug in the adjuvant setting poses unique statistical challenges (as it is difficult to discern the patients who do not relapse due to drug treatment from the vast majority who would not relapse regardless). This problem, which is relevant to all biomarker testing, will be addressed separately.

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12. STUDY CONDUCT CONSIDERATIONS

12.1. Regulatory and Ethical Considerations, Including the Informed Consent Process

GlaxoSmithKline will obtain favorable opinion/approval to conduct the study from the appropriate regulatory agency in accordance with any applicable country-specific regulatory requirements prior to a site initiating the study in that country.

The study will be conducted in accordance with all applicable regulatory requirements, including an US IND.

The study will also be conducted in accordance with "good clinical practice" (GCP), all applicable subject privacy requirements, and, the guiding principles of the Declaration of Helsinki. This includes, but is not limited to, the following:

• Review by Institutional Review Board/Independent Ethics Committee (IRB/IEC) and favorable opinion/approval to conduct the study and of any subsequent relevant amended documents including but not limited to the protocol, the site’s ICF, and any other information that will be presented to potential subjects (e.g., advertisements or information that supports or supplements the informed consent)

• Investigator reporting requirements

GlaxoSmithKline will provide full details of the above either verbally, in writing or both.

Approval by IRB/IEC of the PGx consent forms must be obtained in addition to the approval given for the clinical study. Regulatory review and approval may be required in some countries before IEC/IRB approval can be sought.

Written informed consent will be obtained for each subject before he or she can participate in the study.

12.2. Quality Control (Study Monitoring)

In accordance with applicable regulations, GCP, and GSK procedures, GSK monitors will contact the site prior to the subject enrollment to review the protocol and data collection procedures with site staff. In addition, the monitor will periodically contact the site, including conducting on-site visits. The extent, nature and frequency of on-site visits will be based on such considerations as the study objective and/or endpoints, the purpose of the study, study design complexity, and enrollment rate.

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During these contacts, the monitor will:

• Check the progress of the study.

• Review study data collected.

• Conduct source document verification.

• Identify any issues and address their resolution.

This will be done in order to verify that the:

• Data are authentic, accurate, and complete.

• Safety and rights of subjects are being protected.

• Study is conducted in accordance with the currently approved protocol (and any amendments), GCP, and all applicable regulatory requirements.

The investigator agrees to allow the monitor direct access to all relevant documents and to allocate his/her time and the time of his/her staff to the monitor to discuss findings and any relevant issues.

At study closure, monitors will also conduct all activities described in Section 12.4.

12.3. Quality Assurance

To ensure compliance with GCP and all applicable regulatory requirements, GSK may conduct a quality assurance audit. Regulatory agencies may also conduct a regulatory inspection of this study. Such audits/inspections can occur at any time during or after completion of the study. If an audit or inspection occurs, the investigator and institution agree to allow the auditor/inspector direct access to all relevant documents and to allocate his/her time and the time of his/her staff to the auditor/inspector to discuss findings and any relevant issues.

12.4. Study and Site Closure

Upon completion of the study, the monitor will conduct the following activities in conjunction with the investigator or site staff, as appropriate:

• Return of all study data to GSK.

• Data queries.

• Accountability, reconciliation, and arrangements for unused investigational product(s).

• Review of site study records for completeness.

• Shipment of biomarker, proteomics, and PGx samples to assay laboratory(ies).

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In addition, GSK reserves the right to temporarily suspend or prematurely discontinue this study either at a single site or at all sites at any time for reasons including, but are not limited to, safety or ethical issues or severe non-compliance. If GSK determines such action is needed, GSK will discuss this with the investigator (including the reasons for taking such action) at that time. When feasible, GSK will provide advance notification to the investigator of the impending action prior to it taking effect.

GlaxoSmithKline will promptly inform all other investigators and/or institutions conducting the study if the study is suspended or terminated for safety reasons, and will also inform the regulatory authorities of the suspension or termination of the study and the reason(s) for the action. If required by applicable regulations, the investigator must inform the IEC/IRB promptly and provide the reason for the suspension or termination.

If the study is prematurely discontinued, all study data must be returned to GSK. In addition, arrangements will be made for all unused investigational product(s) in accordance with the applicable GSK procedures for the study.

Financial compensation to investigators and/or institutions will be in accordance with the agreement established between the investigator and GSK.

12.5. Records Retention

Following closure of the study, the investigator or the head of the medical institution (where applicable) must maintain all site study records, except for those required by local regulations to be maintained by someone else, in a safe and secure location. The records must be maintained to allow easy and timely retrieval, when needed (e.g., audit or inspection), and, whenever feasible, to allow any subsequent review of data in conjunction with assessment of the facility, supporting systems, and staff. Where permitted by local laws/regulations or institutional policy, some or all of these records can be maintained in a format other than hard copy (e.g., microfiche, scanned, electronic); however, caution needs to be exercised before such action is taken. The investigator must assure that all reproductions are legible and are a true and accurate copy of the original and meet accessibility and retrieval standards, including re-generating a hard copy, if required. Furthermore, the investigator must ensure there is an acceptable back-up of these reproductions and that an acceptable quality control process exists for making these reproductions.

GlaxoSmithKline will inform the investigator of the time period for retaining these records to comply with all applicable regulatory requirements. The minimum retention time will meet the strictest standard applicable to that site for the study, as dictated by any institutional requirements or local laws or regulations, or GSK standards/procedures; otherwise, the retention period will default to 15 years.

The investigator must notify GSK of any changes in the archival arrangements, including, but not limited to, the following: archival at an off-site facility, transfer of ownership of the records in the event the investigator leaves the site.

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12.6. Provision of Study Results and Information to Investigators

When required by applicable regulations, the investigator signatory for the clinical study report will be determined at the time the report is written. When the clinical study report is completed, GSK will provide the investigator with a full summary of the study results. The investigator is encouraged to share the summary results with the subjects, as appropriate. In addition, the investigator will be given reasonable access to review the relevant statistical tables, figures, and reports and will be able to review the results for the entire study at a GSK site or other mutually agreeable location.

GlaxoSmithKline will provide the investigator with the randomization codes for their site after the statistical analysis for the entire study has been completed.

GlaxoSmithKline may list and summarize the proteomics and PGx research results from coded samples by subject number in the clinical study report. In this event, the investigator and study staff would have access to the research results and would be able to link the results to a particular subject. The investigator and study staff would be directed to hold this information confidentially.

12.7. Information Disclosure and Inventions

12.7.1. Ownership

All information provided by GSK and all data and information generated by the site as parts of the study (other than a subject’s medical records) are the sole property of GSK.

All rights, title, and interests in any inventions, know-how or other intellectual or industrial property rights which are conceived or reduced to practice by site staff during the course of or as a result of the study are the sole property of GSK, and are hereby assigned to GSK.

If a written contract for the conduct of the study which includes ownership provisions inconsistent with this statement is executed between GSK and the study site, that contract’s ownership provisions shall apply rather than this statement.

This includes the results of the biomarker, proteomics and PGx assessments included in the study.

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12.7.2. Confidentiality

All information provided by GSK and all data and information generated by the site as part of the study (other than a subject’s medical records) will be kept confidential by the investigator and other site staff. This information and data will not be used by the investigator or other site personnel for any purpose other than conducting the study. These restrictions do not apply to: (1) information which becomes publicly available through no fault of the investigator or site staff; (2) information which it is necessary to disclose in confidence to an IEC or IRB solely for the evaluation of the study; (3) information which it is necessary to disclose in order to provide appropriate medical care to a study subject; or (4) study results which may be published as described in the next paragraph. If a written contract for the conduct of the study which includes confidentiality provisions inconsistent with this statement is executed, that contract’s confidentiality provisions shall apply rather than this statement.

12.7.3. Publication

For multicenter studies, the first publication or disclosure of study results shall be a complete, joint multicenter publication or disclosure coordinated by GSK. Thereafter, any secondary publications will reference the original publication(s). The study chairman, will be the first author of the main publication.

Prior to submitting for publication, presentation, use for instructional purposes, or otherwise disclosing the study results generated by the site (collectively, a “Publication”), the study chair investigator shall provide GSK with a copy of the proposed Publication and allow GSK a period of at least thirty (30) days [or, for abstracts, at least five (5) working days] to review the proposed Publication. Proposed Publications shall not include either GSK confidential information other than the study results or personal data on any subject, such as name or initials.

At GSK’s request, the submission or other disclosure of a proposed Publication will be delayed a sufficient time to allow GSK to seek patent or similar protection of any inventions, know-how or other intellectual or industrial property rights disclosed in the proposed Publication.

If a written contract for the conduct of the study, which includes publication provisions inconsistent with this statement is executed, that contract’s publication provisions shall apply rather than this statement.

12.8. Data Management

Subject data are collected by the investigator or designee using the eCRF/CRF defined by GSK. In all cases, subject initials will not be collected or transmitted to GSK. A data capture system will be used to collect all of the subject information from the investigator. Subject data necessary for analysis and reporting will be entered/transmitted into a validated database or data system. Clinical data management will be performed in accordance with applicable GSK standards and data cleaning procedures. Database freeze will occur when data management quality control procedures are completed.

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Laboratory data (i.e., hematology and clinical chemistry) will be stored in a database maintained by the central laboratory and transferred to GSK at agreed times.

All other subject data are collected by the investigator or designee using the eCRF designed by GSK.

12.9. Independent Data Monitoring Committee

An IDMC will be convened every 6 months to review accumulating safety data and to provide a recommendation to terminate the study early if there is a concern regarding safety. The specific responsibilities and composition of the IDMC are outlined in a separate document, the IDMC Charter. A copy of the IDMC charter is available from GSK upon request.

The IDMC will also convene to review the safety and efficacy data at the time of the interim analysis as described in Section 11.3.3.

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14. APPENDICES

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14.1. Appendix 1: Time & Events Table

Required Procedure(s)

Screen1

Visits During Treatment (Mos. from Randomization)

Early Study Withdrawal/

Closure/ Month 1227

Follow-up

0 3 6 9

Informed consent (s): clinical, pharmacogenetic2, and biomarker2a X3,4 X2a X2a Inclusion & exclusion criteria X4 X5

Baseline Characteristics

Disease & anti-cancer treatment history X Documentation of ErbB2 overexpression6 X4

Safety7 Physical examination (vital signs, ECOG PS, weight & height) X X X X X X Concomitant medication(s) X X X X X X AE assessment & NCI CTCAE grading (Version 3.0) [National Cancer Institute, 2005]

X X X X X X

12-lead electrocardiogram (ECG) X X Echocardiogram (ECHO) or MUGA8 X X X X X9 X10 Hematology (X) & Chemistry ( 26)11 ± calculate creatinine clearance14

X X12 X X X X13 12

Serum pregnancy X QoL SF-36v2 questionnaire15 X X X X16 Efficacy17 Clinical assessment X X X X X X22,23

Mammography X18 X18 Abdominal & chest CT scan or MRI scan X19 as clinically indicated19 Bone scan X20 as clinically indicated20 Head MRI as clinically indicated21 Survival and poststudy therapy(ies) X22

Biomarker(s) Plasma for proteomics analysis X X Tumor tissue (archived & biopsy at disease recurrence) X4 X4a X4a

PGx Research Pharmacogenetics samples (if applicable) X24 Treatment Dispense study drug & assess compliance X25 X X X

Continued

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14.1 Appendix 1: Time & Events Table (Continued)

1. All screening assessments must be performed within 4 weeks prior to administration of first dose of study drug, unless otherwise indicated. 2. Only subjects who give informed consent to participate in the clinical study, meet all the criteria required for entry into the clinical study, AND receive study drug may be asked to

participate in PGx research; patient participation in PGx research is voluntary and refusal to participate will not lead to withdrawal from the clinical study. 2a). Subjects who have disease recurrence may be asked to voluntarily participate in additional research on biomarkers derived from a tumor tissue biopsy.

3. Signed, written ICF must be obtained prior to screening and baseline assessments, and before any study-specific assessments are initiated, including obtaining archived tumor tissue for biomarker ± tumor genotyping analyses.

4. Must be performed within 6 weeks prior to administration of first dose of study drug and prior to all screening and baseline assessments, and before any study-specific assessments are initiated. 4a). A tumor tissue biopsy from the site of disease recuurence will be obtained in subjects who consent.

5. After all screening evaluations have been completed and the data are obtained, the inclusion and exclusion criteria must be reviewed to confirm subject eligibility. 6. If a tumor tissue block is submitted for ErbB2 testing, this sample can also be used for the biomarker and genetics research (if applicable). Refer to the SRM for preparation of all

tissue requirements and handling instructions. 7. Safety assessment(s) should be performed as often as clinically indicated (in addition to being performed at the time points indicated in the above table), with the exception of

height, which is required to be measured only at screening. For example, all laboratory assessments with significantly abnormal values during participation in the study or within 30 days after the last dose of study drug should be repeated until the values return to normal or baseline.

8. If echocardiogram was not conclusive to evaluate LVEF, a MUGA scan should be done. The same method of cardiac evaluation at screening must be used consistently throughout the study. Refer to Section 7.2.2.1 for criteria for evaluating cardiac events.

9. Do not repeat if the previous cardiac assessment was <12 weeks from the date of study withdrawal/closure. 10. Cardiac function will be assessed between 6 and 9 months after discontinuation of study drug. 11. Refer to Table 6 for details on laboratory assessments. 12. Review screening laboratory results within 3 days of Day 1 dose. Any test yielding a result outside the normal range may be repeated prior to the first dose of study drug at the

discretion of the investigator. Before the first dose of study drug, laboratory results must be within the values outlined in Section 5.2.1, Table 5). 13. Do not repeat if the previous laboratory evaluation was <12 weeks from date of study withdrawal/closure. 14. Calculate using standard Cockcroft and Gault method if serum creatinine >2.0 mg/dL; result must be ≥40 mL/min to be eligible for study enrollment. 15. The SF-36 questionnaire (Version 2) must be completed prior to any other study procedures performed at each visit, including physician interaction. 16. Health-related QoL will be self-assessed every 6 months after discontinuation of study drug for a total of 24 months. 17. Efficacy assessment(s) should be performed when symptoms suggest disease recurrence or a second primary cancer (in addition to being performed at the time points indicated

in the above table). 18. Required if not performed within 12 months prior to study entry. Mammography is required every 12 months from the time of initial diagnosis throughout the treatment and follow-

up phases of the study. 19. Only required if AST ≥2 × ULN, ALT ≥2 × ULN, or ALP ≥2 × ULN (not in the bone fraction) or symptoms suggestive of disease recurrence are present. Chest CT scan or MRI

scan to include the entire liver, or alternatively, separate chest and abdominal CT (or MRI) scans. 20. Only required if ALP ≥2 × ULN in the bone fraction or symptoms suggestive of disease recurrence are present. Bone scan to include evaluation of skull, total spine, clavicle, ribs,

pelvis, and long bones; a confirmatory x-ray, CT scan or MRI scan or a biopsy is required if the results of the bone scan are inconclusive. 21. Only required if neurological symptoms suggestive of disease recurrence are present.

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22. Assessment of efficacy will continue with evaluations as outlined in Table 4. 23. Only for subjects who do not discontinue the study for disease recurrence or second primary cancer. 24. If the patient consents to PGx research, a 10ml blood sample should be collected on Day 1 (prior to the first dose). 25. A 3-month supply (six bottles each containing 90 tablets) of lapatinib or placebo will be dispensed. Lapatinib or placebo is to be taken once daily at approximately the same time

each day either 1 hour (or more) before a meal or 1 hour (or more) after a meal (for example, 1 hour before or after breakfast each day). Study drug is not to be taken with grapefruit or grapefruit juice.

26. Standard chemistry must be performed every 6 weeks or more frequently if clinically indicated during the study drug treatment phase to allow for close monitoring of liver chemistry results (refer to Section 7.2.2.2 for liver chemistry stopping rules and follow up criteria).

27. All assessments at this visit should be performed on or as soon as possible after early discontinuation or completion of study drug day.

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14.2. Appendix 2: Pharmacogenetic Research

Pharmacogenetics in Oncology

Background

Pharmacogenetics (PGx) is the study of variability in drug response due to hereditary factors in different populations. There is increasing evidence that an individual's genetic composition (i.e., genotype) may impact the pharmacokinetics (absorption, distribution, metabolism, elimination), pharmacodynamics (relationship between concentrations and pharmacologic effects or the time course of pharmacologic effects) and/or clinical outcome (in terms of efficacy and/or safety and tolerability). Some reported examples of PGx analysis in oncology include:

Drug Disease Gene Outcome 6-mercaptopurine (6-MP)

Lymphoblastic leukemia

S-methyltransferase Deficiency of the TPMT enzyme can be associated with toxicity and severe myelosuppression as subjects are not able to sufficiently clear active thioguanine nucleotides [McLeod, 2002; Cheng, 2005]

5-fluoruracil (5-FU) Colorectal cancer

Dihydropyrimidine dehydrogenase (DPD)

Variants in the DPD gene result in little or no DPD and predisposition to toxicity to 5-FU [Mattison, 2002; Van Kuilenburg, 2002]

Paclitaxel Ovarian cancer MDR1 (ABCB1) Subjects possessing the 3435T allele had significantly greater exposure (AUC) and worse leukopenia [Nakajima, 2005]

Irinotecan (CPT11) Colorectal cancer

UGT1A1 Subjects having the genotype associated with clinically benign Gilbert’s Syndrome are at increased risk of severe drug-induced neutropenia due to higher levels of the active metabolite, SN-38 [Ando, 2000; Innocenti, 2004]; these genotypes also appear to be associated with higher tumor response rates [Carlini, 2005]

It should be noted that at least in the case of Irinotecan, the pharmacogenetic ability to predict for life-threatening toxicity (Grade 4 neutropenia) are being translated into regulatory-mandated studies and may lead to a clinical test in the near future to enable individualized dosing based on genotype. A key component to successful PGx research is the collection of samples during the conduct of clinical studies, without which such progress cannot be made.

The crucial role that underlying genetic abnormalities play in response to TKIs targeting the ErbB family has been underscored by recent reports documenting a very strong correlation between activating point mutation in the tyrosine kinase domain of ErbB1 and clinical responses to both gefitinib [Paez, 2004; Lynch, 2004] and erlotinib [Pao, 2004] in lung cancer, where similar activating mutations (but without amplification) have been observed in ErbB2 [Stephens, 2004]. It is clear from these recent data that to understand tumor response to targeted therapy, the underlying genetic changes specific to the cancer cells must be analyzed. These appear to include both mutations and copy number changes, at least of the targeted genes. However, other less apparent genetic changes may also influence response. For example, clinical benefit from trastuzumab appears to

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correlate not only to ErbB2 amplification (as a prerequisite), but also to an intact PTEN tumor suppressor gene, such that loss of PTEN predicts trastuzumab failure even when ErbB2 is amplified [Nagata, 2004]. Thus, complete genetic analyses should include not only directed sequencing for mutations but the elucidation of both amplification and deletions, as can be done in an unbiased fashion by genome-wide array comparative genomic hybridization. This more comprehensive approach will enable investigators to utilize recent technological advances to detect genetic aberrations present in a particular patient's tumor (paraffin embedded) so that investigators may improve the ability to predict likely responders to lapatinib. In addition, the large sample size and adjuvant setting will provide a unique opportunity to contribute to the academic mission of defining new and validating existing biomarkers of disease recurrence, whether protein-, RNA-, or DNA-based.

Pharmacogenetic Research Objectives

If at any time it appears there is potential variability in response in this clinical study or in a series of clinical studies with lapatinib that may be attributable to genetic variations of subjects, the following objectives may be investigated:

• relationship between genetic variants and safety and/or tolerability of lapatinib

• relationship between genetic variants and efficacy of lapatinib

Study Population

Any subject who has given informed consent to participate in the clinical study has met all the entry criteria for the clinical study and receives investigational product, may take part in the PGx research. Any subject who has received an allogeneic bone marrow transplant must be excluded from the PGx research.

Subject participation in PGx research is voluntary and refusal to participate will not indicate withdrawal from the clinical study. Refusal to participate will involve no penalty or loss of benefits to which the subject would otherwise be entitled.

Study Assessments and Procedures

Blood samples for pharmacogenetic research will be obtained throughout the study (refer to the Time & Events Table in Section 14.1, Appendix 1).

In addition to any blood samples taken for the clinical study, a whole blood sample (~10ml) will be collected for the PGx research using a tube containing EDTA. The PGx sample is labelled (or “coded”) with a study specific number that can be traced or linked back to the subject by the investigator or site staff. Coded samples do not carry personal identifiers (such as name or social security number). The blood sample will be taken on a single occasion unless a duplicate sample is required due to inability to utilize the original sample. It is recommended that the blood sample be taken at the first opportunity (i.e., first visit) after a subject has been randomized and provided informed consent for PGx research, but may be taken at any time while the subject is participating in the clinical study.

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If deoxyribonucleic acid (DNA) is extracted from the blood sample, the DNA may be subjected to sample quality control analysis. This analysis will involve the genotyping of several genetic markers to confirm the integrity of individual samples. If inconsistencies are noted in the analysis, then those samples may be destroyed.

Subject Withdrawal from Study

If a subject who has consented to participate in PGx research withdraws from the clinical study for any reason other than lost to follow-up, the subject will be given the following options concerning the PGx sample, if already collected:

• PGx research continues as per the subject’s consent; or,

• Any remaining sample is destroyed

If a subject withdraws consent from the PGx research or requests sample destruction, the investigator must complete the appropriate documentation to request sample destruction within the timeframe specified by GSK and maintain the documentation in the site study records. In either case, GSK will only keep study information collected/generated up and until that point.

Screen and Baseline Failures

If a blood sample for PGx research has been collected and it is determined that the subject does not meet the entry criteria for participation in the clinical study, then the investigator must complete the appropriate documentation to request sample destruction within the timeframe specified by GSK and maintain the documentation in the site study records.

Pharmacogenetics Analyses

The need to conduct PGx analysis may be identified after a study (or set of studies) of lapatinib has been completed and the study data reviewed. For this reason, samples may be kept for up to 15 years after the last subject completes the study or GSK may destroy the samples sooner. In special cases, the samples may not be studied. This might happen if there are not enough subjects, if the study is stopped for other reasons, or if no questions are raised about how people respond lapatinib.

Generally GSK will utilize two approaches to explore genetic variation in drug response.

• Specific sections of DNA may be selected from areas of the genome (e.g., candidate genes) known to encode the drug target, drug metabolizing enzymes, areas associated with mechanisms underlying adverse events, and those linked to study disease and, thus, linked to drug response.

The candidate genes that may be investigated in this study include ABCB1 (MDR1), ABCG2, ERBB2, among others. Gefitinib, a ERBB1-specific TKI, both affects ABCG2 function [Nakamura, 2005] and is affected by it [Elkind, 2005]. The likelihood of developing cardiotoxicity following trastuzumab therapy may be affected by a common polymorphism in its target gene, ERBB2 [Milano, 2005].

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In addition, continuing research may identify other enzymes, transporters, proteins, or receptors that may be involved in response to lapatinib. The genes that may code for these proteins may also be studied.

• By evaluating large numbers of polymorphic markers (e.g., single nucleotide polymorphisms or SNPs) throughout the genome, sets of markers may be identified that correspond to differential drug response.

Hardy-Weinberg Equilibrium Testing

The genotypic frequencies of each polymorphism will be evaluated for conformity to those expected under normal conditions by employing Hardy-Weinberg Equilibrium testing.

Comparison of Demographic and Baseline Characteristics by Genotype

Differences in baseline clinical characteristics and potential contributing covariates may be summarized and compared among genotype (or haplotype) subgroups.

Evaluation of Genotypic Effects

Analyses may be carried out to evaluate the degree of association between subject genotype (or haplotype) and selected parameters (e.g., efficacy and safety), such as skin rash, diarrhoea, and heart failure. Where such genotypic tests are inappropriate (for example, where the number of marker genotypes is too large and/or the frequency of individual genotypes too small), allelic tests may be conducted. Allelic tests evaluate whether the frequency of each marker allele is the same in responders and non-responders.

Evaluation of Treatment by Genotype and Gene-Gene Interaction

In addition to evaluating the main effects of the genotypes (haplotypes or alleles) on the selected parameters, the possibility of a treatment group by genotype (haplotype or allele) interaction will also be explored. If appropriate, the joint effects of multiple markers (gene-gene interactions) may also be evaluated.

Linkage Disequilibrium

For pairs of polymorphisms, the degree to which alleles from the two sites are correlated (linkage disequilibrium) may also be evaluated. If the genotypes at two polymorphic sites within a gene are shown to be statistically associated with a response to investigational product, the degree of linkage disequilibrium will aid interpretation in that it will indicate the extent to which the two sites are exerting independent effects.

Multiple Comparisons and Multiplicity

To the extent that multiple markers are evaluated (especially in the case of a genome scan for association), an adjustment to observed p-values may be made to limit erroneous conclusions due to multiple tests.

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Power and Sample Size Considerations

The ability to detect differential drug response among genotypes at a polymorphic site depends on the total number of subjects genotyped and the frequency distribution of the different genotypes. Consequently, genotyping analyses are plausible for those polymorphic sites where the number of subjects comprising the genotypic groups is sufficiently large; however, these frequencies will not be known until sufficient samples have been collected and genotyping is complete.

Estimates of sample sizes required to demonstrate genotype effects vary considerably depending on the assumptions made about allele frequency, genetic effect size and mechanism of inheritance [Cardon, 2000]. In the work by Palmer and Cookson [Palmer, 2001], which assumed a genotype relative risk of 1.5, it was estimated that more than 300 cases and 600 controls would be needed to conduct a genetic association analysis. In contrast, McCarthy and Hilfiker [McCarthy, 2000] showed that with a genotype relative risk of 2.16 and a relatively commonly occurring genotype, only 30 cases and 30 controls would be needed to demonstrate an association. Additional published examples showing that a small sample sizes (as is typically encountered in Phase I and Phase II studies in oncology) may be sufficient to identify clinically relevant genetic associations include abacavir hypersensitivity reaction [Hetherington, 2002] and tranilast induced hyperbilirubinemia [Roses, 2002].

Informed Consent

Subjects who do not wish to participate in the PGx research may still participate in the clinical study. PGx informed consent must be obtained prior to any blood being taken for PGx research.

Provision of Study Results and Confidentiality of Subject’s Pharmacogenetic Data

GlaxoSmithKline may summarize the cumulative PGx research results in the clinical study report. In general, GSK does not inform the investigator, subject or anyone else (e.g., family members, study investigators, primary care physicians, insurers, or employers) of the PGx research results because the information generated from PGx studies is preliminary in nature, and the significance and scientific validity of the results are undetermined at such an early stage of research, under any circumstance unless required by law.

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References

Ando, Y., H. Saka, et al. (2000). "Polymorphisms of UDP-glucuronosyltransferase gene and irinotecan toxicity: a pharmacogenetic analysis." Cancer Res 60(24): 6921-6.

Cardon, L. R., R. M. Idury, et al. (2000). "Testing drug response in the presence of genetic information: sampling issues for clinical trials." Pharmacogenetics 10(6): 503-10.

Carlini, L. E., N. J. Meropol, et al. (2005). "UGT1A7 and UGT1A9 polymorphisms predict response and toxicity in colorectal cancer patients treated with capecitabine/irinotecan." Clin Cancer Res 11(3): 1226-36.

Cheng, Q., W. Yang, et al. (2005). "Karyotypic abnormalities create discordance of germline genotype and cancer cell phenotypes." Nat Genet 37(8): 878-82.

Elkind, N. B., Z. Szentpetery, et al. (2005). "Multidrug transporter ABCG2 prevents tumor cell death induced by the epidermal growth factor receptor inhibitor Iressa (ZD1839, Gefitinib)." Cancer Res 65(5): 1770-7.

Hetherington, S., A. R. Hughes, et al. (2002). "Genetic variations in HLA-B region and hypersensitivity reactions to abacavir." Lancet 359(9312): 1121-2.

Innocenti, F., S. D. Undevia, et al. (2004). "Genetic variants in the UDP-glucuronosyltransferase 1A1 gene predict the risk of severe neutropenia of irinotecan." J Clin Oncol 22(8): 1382-8.

Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, Harris PL, Haserlat SM, Supko JG, Haluska FG, Louis DN, Christiani DC, Settleman J, Haber DA. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. New Engl J Med. 2004;350(21):2129-39.

Mattison, L. K., R. Soong, et al. (2002). "Implications of dihydropyrimidine dehydrogenase on 5-fluorouracil pharmacogenetics and pharmacogenomics." Pharmacogenomics 3(4): 485-92.

McCarthy, J. J. and R. Hilfiker (2000). "The use of single-nucleotide polymorphism maps in pharmacogenomics." Nat Biotechnol 18(5): 505-8.

McLeod, H. L. and C. Siva (2002). "The thiopurine S-methyltransferase gene locus -- implications for clinical pharmacogenomics." Pharmacogenomics 3(1): 89-98.

Milano, G. A., W. Lescaut, et al. (2005). HER2 genetic polymorphism and pharmacodynamics of trastuzumab-based treatment in breast cancer patients. American Society of Clinical Oncology.

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Nagata Y, Lan KH, Zhou X, Tan M, Esteva FJ, Sahin AA, Klos KS, Li P, Monia BP, Nguyen NT, Hortobagyi GN, Hung MC, Yu D. PTEN activation contributes to tumor inhibition by trastuzumab, and loss of PTEN predicts trastuzumab resistance in patients. Cancer Cell. 2004;6(2):117-27.

Nakajima, M., Y. Fujiki, et al. (2005). "Pharmacokinetics of paclitaxel in ovarian cancer patients and genetic polymorphisms of CYP2C8, CYP3A4, and MDR1." J Clin Pharmacol 45(6): 674-82.

Nakamura, Y., M. Oka, et al. (2005). "Gefitinib ("Iressa", ZD1839), an epidermal growth factor receptor tyrosine kinase inhibitor, reverses breast cancer resistance protein/ABCG2-mediated drug resistance." Cancer Res 65(4): 1541-6.

Palmer, L. J. and W. O. Cookson (2001). "Using single nucleotide polymorphisms as a means to understanding the pathophysiology of asthma." Respir Res 2(2): 102-12.

Paez JG, Janne PA, Lee JC, Tracy S, Greulich H, Gabriel S, Herman P, Kaye FJ, Lindeman N, Boggon TJ, Naoki K, Sasaki H, Fujii Y, Eck MJ, Sellers WR, Johnson BE, Meyerson M. EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science. 2004;304(5676):1497-500.

Pao W, Miller V, Zakowski M, Doherty J, Politi K, Sarkaria I, Singh B, Heelan R, Rusch V, Fulton L, Mardis E, Kupfer D, Wilson R, Kris M, Varmus H. EGF receptor gene mutations are common in lung cancers from "never smokers" and are associated with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci. 2004;101(36):13306-11.

Roses, A. D. (2002). "Genome-based pharmacogenetics and the pharmaceutical industry." Nat Rev Drug Discov 1(7): 541-9.

Stephens P, Hunter C, Bignell G, Edkins S, Davies H, Teague J, Stevens C, O'Meara S, Smith R, Parker A, Barthorpe A, Blow M, Brackenbury L, Butler A, Clarke O, Cole J, Dicks E, Dike A, Drozd A, Edwards K, Forbes S, Foster R, Gray K, Greenman C, Halliday K, Hills K, Kosmidou V, Lugg R, Menzies A, Perry J, Petty R, Raine K, Ratford L, Shepherd R, Small A, Stephens Y, Tofts C, Varian J, West S, Widaa S, Yates A, Brasseur F, Cooper CS, Flanagan AM, Knowles M, Leung SY, Louis DN, Looijenga LH, Malkowicz B, Pierotti MA, Teh B, Chenevix-Trench G, Weber BL, Yuen ST, Harris G, Goldstraw P, Nicholson AG, Futreal PA, Wooster R, Stratton MR. Lung cancer: intragenic ERBB2 kinase mutations in tumours. Nature. 2004;431(7008):525-6.

Van Kuilenburg, A. B., R. Meinsma, et al. (2002). "High prevalence of the IVS14 + 1G>A mutation in the dihydropyrimidine dehydrogenase gene of patients with severe 5-fluorouracil-associated toxicity." Pharmacogenetics 12(7): 555-8.

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14.3. Appendix 3: American Joint Committee on Cancer Staging Criteria

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14.4. Appendix 4: ECOG Performance Status Scale

Data Source: [Oken, 1982] Abbreviations: ECOG = Eastern Cooperative Oncology Group

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14.5. Appendix 5: Cockcroft and Gault Method for Calculated Creatinine Clearance

Creatinine clearance can be calculated from serum creatinine values by one of the two formulas below:

Calculated creatinine clearance (mL/min) =

(140 − age [yrs] ) × weight (kg) 72 × serum creatinine (mg/DL)

Female patients: multiply by 0.85 In order to use SI units for creatinine (µmol/L), the following formula may be used.


(140 − age [yrs] ) × weight (kg) x 88.4 72 × 1 × serum creatinine (µmol/L))

Female patients: multiply by 0.85 Data Source: [Cockcroft, 1976]

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14.6. Appendix 6: 36-Item Short Form (Version 2) Health Survey

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14.7. Appendix 7: Country Specific Requirements

There are no country specific requirements.

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14.8. Appendix 8: Protocol Changes

Amendment 1 Changes

The original Protocol date, 21 April 2006, is replaced by Amendment No. 01, 29 September 2006. This amendment applies to all participating investigative sites in France.

The following protocol changes have been implemented as a result of comments received by the French Comité de Protection des Personnes (CPP).

Original text is displayed and strike-through indicates replaced or removed text. New text is displayed with an underline.

Summary of Changes

1. Inclusion Criteria: Section 5.2.1

6. All women eligible for adjuvant treatment with trastuzumab, including those diagnosed and treated within the last six months, must be considered for such treatment prior to being offered participation in this study. Participation in this study will be allowed only if women who have not received trastuzumab in the adjuvant setting, but are eligible for such treatment, are allowed to participate in this study provided the physician and patient have considered and discussed at length the advantages of trastuzumab, but have mutually decided against initiating trastuzumab therapy. the treatment and decided not to initiate therapy with trastuzumab, for practical reasons. Clear documentation of such a decision must appear in the Electronic Case Report Form (eCRF). Reasons for such decisions may include (but are not limited to) reasons such as living remote to the nearest infusion center and inability to travel weekly for treatment infusions, lack of intravenous access and refusal to obtain indwelling devices;

Reason for change: In the adjuvant treatment setting for patients with ErbB2-overexpressing primary breast cancer, trastuzumab may be initiated within 6 months following the completion of adjuvant chemotherapy in France, in accordance with national and European standard of care. Inclusion Criterion #6 was changed to coincide with the current indication of trastuzumab in France.

2. Appendices: Section 14

14.7 Appendix 7: Country Specific Requirements

There are no country specific requirements.

Reason for change: This appendix was inadvertently omitted from the original protocol.

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Amendment 2 Changes

The country-specific (France) Protocol Amendment 01 date, 29 September 2006, is replaced by Amendment No. 02, 31 January 2007. This amendment applies to all global participating investigative sites.

The following protocol changes have been implemented as a result of comments raised following submission to various IRB/IEC and regulatory bodies and following globally attended investigator meetings.


1. Section 1.1.2.1.1. Theoretical Advantage of Dual Inhibition and Section 13. References

These data suggest that a dual ErbB1 and ErbB2 inhibitor may provide improved therapeutic benefit as compared with inhibitors that target either receptor alone [Rusnak, 2001] [Rusnak, 2001].

Rusnak DW, Affleck K, Cockerill SG, Stubberfield C, Harris R, Page M, Smith KJ, Guntrip SB, Carter MC, Shaw RJ, Jowett A, Stables J, Topley P, Wood ER, Brignola PS, Kadwell SH, Reep BR, Mullin RJ, Alligood KJ, Keith BR, Crosby RM, Murray DM, Knight WB, Gilmer TM, Lackey K. The characterization of novel, dual ErbB-2/EGFR, tyrosine kinase inhibitors: potential therapy for cancer. Cancer Res. 2001;61:7196-203.

Rusnak DW, Lackey K, Affleck K, Wood ER, Alligood KJ, Rhodes N, Keith BR, Murray DM, Knight WB, Mullin RJ, Gilmer TM. The effects of the novel, reversible, EGFR/ErbB-2 tyrosine kinase inhibitor, GW572016, on the growth of human normal and tumor-derived cell lines in vitro and in vivo. Molecular Cancer Therapeutics. 2001;1:85-94.

Reason for change: This was a correction to a reference cited in the protocol.

2. Section 2.2 Secondary Objectives for Translational, Proteomic and Pharmacogenetic Research; Section 3.2. Secondary Endpoints for Translational, Proteomic and Pharmacogenetic Research; Section 4. Study Design; Section 6.5. Biomarkers and Section 11.3.8. Biomarker(s) Analyses

Section 2.2.3. Translational Research

The translational research objective of the study is:

• to identify tumor-derived or blood-derived biomarkers (encoded in protein and RNA) that correlate with or are predictive of clinical response/benefit to lapatinib using transcriptional profiling, immunohistochemistry (IHC) and analysis of genetic aberrations in somatic DNA derived from the tumor tissue obtained at the time of initial diagnosis (archived tumor tissue sample).

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• to compare biomarkers (encoded in protein, RNA, or DNA) derived from the archived tumor tissue sample to those derived from a tumor biopsy sample obtained at the time of disease recurrence (a separate companion protocol has been written to encompass this study).

Section 2.2.4. Proteomic Research

The proteomic research objectives of the study are:

• to identify protein biomarkers present at baseline that could be predictive of clinical response/benefit to lapatinib.

• to identify protein biomarkers that correlate with clinical response/benefit to lapatinib.

Section 2.2.5 2.2.4. Pharmacogenetic Research

The pharmacogenetic (PGx) research objective of the study is:

• to investigate the relationship between genetic variations in select candidate genes in the host or tumor DNA and response (safety, efficacy and tolerability) following treatment with lapatinib (refer to Section 14.2, Appendix 2 for full details on PGx research of this study).

Section 3.2.3. Translational Research

The translational research endpoints are:

• determination of transcriptional profile at baseline and correlation with clinical response/benefit to lapatinib.

• determination of the relationship between somatic genetic aberrations [mutations, deletions, amplifications in genes such as, ErbB1, ErbB2, phosphatase and tensin homolog (PTEN), etc.] in the pre-treatment biopsy that correlate with clinical response/benefit to lapatinib;

• using immunohistochemistry (IHC) and transcriptional profiling or the like, determination of the relationship between baseline expression of intra-tumoral biomarkers [e.g., ErbB1, ErbB2, insulin-like growth factor-1 receptor (IGF1R)] from pre-treatment tumor biopsies and correlation with clinical response/benefit to lapatinib;

• comparison of biomarkers derived from the tumor tissue from initial diagnosis with those derived from the tumor tissue obtained at time of disease recurrence;

• evaluation of the protein profile in plasma samples at baseline and at disease recurrence that correlate with or are predictive of clinical response/benefit to lapatinib.

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Section 3.2.4. Proteomic Research

The proteomics research endpoint is:

• evaluation of the protein profile in plasma samples from baseline and at disease recurrence to identify biomarkers that are either predictive or correlate with clinical response/benefit to lapatinib.

Section 3.2.5. Pharmacogenetics Research

The PGx research endpoint is:

• evaluation of the presence/absence of genetic variations in select candidate genes in the host or tumor DNA and the response (safety, efficacy and tolerability) to lapatinib therapy.

Section 4. Study Design

Women will be screened at baseline and those eligible will be randomly assigned in 1:1 fashion to receive adjuvant therapy with either double-blind lapatinib (Arm A) or placebo (Arm B). During the blinded treatment period, lapatinib 1500mg or matching placebo will be administered orally QD (refer to Section 7.3 for rationale for dose selection of lapatinib). Treatment will continue for a maximum of 12 months (1 year) or until disease recurrence or development of a second primary cancer, unacceptable toxicity, or consent withdrawal (refer to Section 9 for further details on subject completion and withdrawal). Screening assessments and clinical safety, health-related QoL, and efficacy evaluations to assess toxicity and response to the study drug will be performed according to the Time and Events Table (refer to Section 14.1, Appendix 1). Women enrolled in the clinical study are eligible for participation in the PGx research; however, participation is optional (refer to Section 14.2, Appendix 2 for details on PGx research for this study). Women enrolled in the clinical study who have a recurrence of their disease are eligible for participation in additional translational research; however, participation is optional (refer to Section 6.5.1 for details on translational research for this study). In addition, a two sub-studyies will be conducted. In one of the sub-studies, a A subset of women enrolled in the clinical protocol will be eligible to participate in a specific sub-study evaluating QT/QTc interval. This sub-study will be conducted in selected investigative centers and a separate companion protocol has been written to encompass this study. In the other sub-study, women enrolled in the clinical protocol who have disease recurrence will be eligible to participate. This sub-study will compare biomarkers encoded in protein (e.g., IHC for PTEN), DNA (e.g., cMYC amplification), and RNA of the archived tumor tissue sample to that of the tumor biopsy sample obtained at disease recurrence. All investigative centers participating in the clinical protocol will be allowed to conduct this sub-study; a separate companion protocol has been written to encompass this study. Participation in either sub-study is optional.

Section 6.5. Biomarkers Translational Research

Section 6.5.1. Tumor Tissue (Primary Tumor)

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All patients enrolled in the clinical trial are required to participate in the following translational research described herein. Paraffin-embedded tissue blocks (or sections) from archived tumor tissue samples (from time of original diagnosis) will be tested retrospectively to determine biomarkers (for example, ErbB1/2, PTEN, AKT, MAPK, ErbB1 and ErbB2 receptors) that correlate with or are predictive of clinical response/ benefit to lapatinib using appropriate technologies including transcriptional profiling and IHC. intra-tumoral expression levels of proteins relevant to ErbB1/ErbB2 signaling (for example, ErbB1/2 and phosphorylated ErbB1 and ErbB2, PTEN, AKT, MAPK, and potentially other biomarkers that are downstream of ErbB1 and ErbB2 receptors). In addition, transcriptional profiling as well as mRNA profiling may be carried out to define RNA profiles relevant to the objectives stated above.

Patients enrolled in the clinical trial are also eligible to participate in additional translational research described herein; however, participation is optional. Finally, since a Ample evidence exists to link primary genetic aberrations (mutations, amplifications, and deletions) with both disease progression and response to targeted therapies. Therefore, analyses of genetic aberrations in somatic DNA derived from the archived tumor tissue sample such aberrations in ErbB1, ErbB2, k-ras and other relevant genes will also be performed. from tumor-derived DNA isolated from patients that consent to tumor genetic testing. In addition, a tumor tissue biopsy will be obtained from patients who have recurrence of their disease. The biomarkers derived from the archived tumor tissue sample will be compared with the biomarkers derived from the tumor tissue biopsy taken from the site of disease recurrence.

Approximately fifteen (15) twenty (20) slides of paraffin-embedded tissue (or a tissue block of sufficient size to make 15 20 slides) from the tumor obtained at the initial diagnosis (archived tumor tissue) should be sent to GSK for testing. In addition, twenty (20) slides should be sent from the paraffin-embedded tissue biopsy taken from the site of disease recurrence. The genetic studies Analyses will be carried out at GSK laboratories or laboratories associated with GSK in the United States and/or Europe.

Section 6.5.3. Pharmacogenetic Research

Refer to Section 14.2, Appendix 2 for details on PGx research for this study.

Section 11.3.8. Biomarker(s) Analyses

Biomarkers derived from protein expression in the tumor will be tested retrospectively from archived tumor tissue obtained at the time of diagnosis. This may include the 4 epidermal growth factor receptor family members (ErbB1, ErbB2, ErbB3, and ErbB4), AKT, MAPK, and potentially other biomarkers that are downstream of ErbB1 and ErbB2 receptors. In addition, biomarkers derived from the archived tumor tissue sample will be compared with the biomarkers derived from the tumor tissue biopsy taken from the site of disease recurrence.

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Section 9.2.2. Subject Withdrawal from Study Drug

When applicable, all subjects who withdraw from study drug must continue to be followed for the study assessments and procedures, including follow-up procedures, as defined in Section 6 and at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1. Subjects who have disease recurrence may be asked to participate in additional research on biomarkers derived from a tumor tissue biopsy; participation is optional and refusal to participate will not lead to withdrawal from the clinical study.

Reason for change: The above sections were modified to include details of the tissue biopsy to be obtained from the tumor site of disease recurrence. A comparison of biomarkers from a tumor tissue obtained at the time of initial diagnosis (pre-treatment) with those from the tumor tissue obtained at the time of disease recurrence (post-treatment) will be performed to elucidate the influence of treatment with lapatinib on biomarkers.

3. Section 2.2. Secondary Objectives for Efficacy Section 2.2.1. Efficacy

• to evaluate and compare between treatment arms the change in quality of life (QoL), change in QoL relative to baseline, and quality-adjusted survival using the Medical Outcomes Study (MOS) 36-item short-form (SF-36 v2) acute recall [Ware, 1992; McHorney, 1993; Ware, 2001] (refer to Section 14.6, Appendix 6 for health survey).

Reason for change: To clarify that QoL assessment will focus on the differences in QoL scores between the treatment arms.

4. Section 4. Study Design After study drug withdrawal or completion of 12-month treatment period, all women will be assessed for information on survival and additional anti-cancer therapies. For women who withdraw from or complete treatment without recurrence of disease or development of a second primary cancer, clinical assessments of disease status will continue. The frequency of efficacy assessments will vary depending on the time interval between the date of initial diagnosis and the date of study drug withdrawal or completion. Assessment of efficacy will continue until death with evaluations as outlined according to Table 4.

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Table 4 Efficacy Assessments after Early Study Drug Withdrawal or Completion of 12-Month Treatment Period

Time from Initial Diagnosis to Study Drug Withdrawal

Frequency of Assessments

Duration

≤2 years every 3 months reassess until >2 years post-diagnosis >2 to 5 years every 6 months reassess until >5 years post-diagnosis >5 years

every 12 months

reassess until death or until a maximum of 10 years after the last patient was enrolled, whichever comes first

1. assessments include evaluation of disease recurrence or second primary cancer in women who discontinued the study without evidence of disease recurrence or second primary cancer, and evaluation of survival and anti-cancer therapies in all women.

2. assessments will continue until death.

Time from Initial Diagnosis to Study Drug Withdrawal or Completion

Frequency of Assessments1

≤2 years every 3 months until >2 years post-diagnosis2 >2 to 5 years every 6 months until >5 years post-diagnosis2 >5 years

every 12 months until death or until 10 years after the date of study drug withdrawal or completion, whichever comes first

1. assessments include evaluation of disease recurrence or second primary cancer in women who discontinued or completed the study drug without evidence of disease recurrence or second primary cancer, and evaluation of survival and anti-cancer therapies in all women.

2. once the stated post-diagnosis timepoint is met, refer to the next line in the table The primary analysis (after 4639 women have disease recurrence, a second primary cancer, or have died) will test whether lapatinib is superior to placebo with respect to DFS. One interim analysis will be performed after 30913 women have disease recurrence, a second primary cancer, or have died. A Haybittle-Peto O’Brien & Fleming stopping boundaryies will be used to detect superiority of lapatinib [O’Brien, 1979]. To preserve the integrity of the study blind, an Independent Data Monitoring Committee (IDMC) will be convened to periodically review the accumulating safety and the efficacy and safety data for the interim analysis. The results of the interim analyses will only be known to the IDMC, and any recommendation to terminate the trial would not be based solely on statistical grounds (refer to Section 11.3.3 for details on the IDMC and interim analysis).

Reason for change: To clarify that efficacy assessments will continue upon study drug withdrawal or completion and will be performed for a total of 10 years after a subject withdraws from or completes study drug therapy. Text regarding final and interim analysis was modified for consistency with amendments made in Section 11.3.3.

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5. Section 5.2.1. Inclusion Criteria #3, #5, #7, #9, #10, #11, #20, and #24 3. Using the American Joint Committee on Cancer (6th edition) staging criteria for

breast cancer [Greene, 2002] (refer to Section 14.3, Appendix 3), a woman must have Stage I through Stage IIIcb disease meeting one of the following criteria:

• node-positive disease defined as one positive lymph node by sentinel node biopsy OR at least 1 positive lymph node found among at least 6 axillary nodes must be examined on axillary node dissection with at least 1 positive lymph node. OR status post axillary radiotherapy for sterilization if clinically evaluated as cN1 or cN2 (Iif sentinel node biopsy is positive, subject may either undergo an axillary node dissection or radiotherapy to the axilla).

• node-positive disease must be evaluated as the following:

• by clinical evaluation, ipsilateral axillary lymph nodes must be cN0-2;

• by pathological evaluation, axillary lymph nodes must be pNX, pN0(i+), or pN1-3pN0-2; for pN0(I+), axillary dissection will be at the discretion of the investigator; for subjects with pN3 (Stage IIIc disease), subjects must be disease free (as determined by physical examination, medical history, and mammogram of preserved breast and/or contralateral breast) following completion of neoadjuvant or adjuvant chemotherapy for at least 12 months and must not have been lost to follow up.

• one positive lymph node by sentinel node biopsy or at least 6 axillary nodes must be examined on axillary node dissection with at least 1 positive lymph node. If sentinel node biopsy is positive, subject may either undergo an axillary node dissection or radiotherapy to the axilla;

• OR

• node-negative disease defined as negative sentinel node biopsy OR no positive lymph nodes found among at least 6 axillary nodes examined on axillary node dissection OR status post axillary radiotherapy for sterilization if clinically evaluated as cN0.

• node-negative disease must be and categorized as either:

• high-risk disease defined as:

• tumor >2.0 cm if ER and/or progesterone receptor (PgR) positive disease is present OR tumor >1.0 cm if ER and PgR negative disease;

• OR

• intermediate-risk disease defined as:

• tumor 1.0-2.0 cm and ER and/or PgR positive disease.

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Reason for change: To clarify definitions of node-positive and node-negative disease and to correct the pathological staging of node-positive disease; pN0 was removed. In addition, subjects with pathological staging of pN3 (Stage IIIc) as defined above are now eligible for this trial.

5. Have completed all primary neoadjuvant or adjuvant chemotherapy regimens prior to study enrollment. However, adjuvant endocrine therapy and radiotherapy may continue as described in Inclusion Criteria #11 and #13, respectively. For women who received an anthracycline-based adjuvant regimen, the interval between the completion of this therapy and study entry must be at least 4 weeks and all therapy-related toxicity must be resolved.

10. Must have received a prior neoadjuvant or adjuvant chemotherapy regimen containing either an anthracycline or a taxane; or any cyclophosphamide, methotrexate and 5-fluorouracil (CMF) regimen;

Reason for change: To clarify that a subject may have received the required prior chemotherapy in the neoadjuvant setting.

7. Have clinical and radiologic assessments, as described below, that are negative for local or regional recurrence of disease or metastatic disease at the time of study entry:

• clinical assessment:

• if signs or symptoms suggestive of either recurrence of disease or metastatic disease are present, the appropriate radiological imaging must be performed;

• laboratory and radiologic assessments:

• if bone fraction of alkaline phosphatase (ALP) ≥2 × upper limit of normal (ULN), a bone scan must be performed. A confirmatory x-ray, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan or biopsy is required if the results of the bone scan are inconclusive.

• if aspartate aminotransferase (AST) or alanine aminotransferase (ALT) or ALP ≥2 × ULN, unless the elevation of ALP is in the bone fraction, an abdominal CT or MRI scan must be performed;

• if the following laboratory results are present, the appropriate radiological imaging must be performed;

Laboratory Value Radiological Imaging AST ≥2 × ULN abdominal CT or MRI scan ALT ≥2 × ULN abdominal CT or MRI scan ALP ≥2 × ULN (not in the bone fraction) abdominal CT or MRI scan ALP ≥2 × ULN in the bone fraction bone scan; a confirmatory x-ray, CT scan or MRI

scan or biopsy is required if the results of the bone scan are inconclusive

Abbreviations: ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; CT = computed tomography; MRI = magnetic resonance imaging; ULN = upper limit of normal

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• bilateral mammogram required if not performed within 12 months prior to study entry. If the initial surgery was a total mastectomy, only a mammogram of the remaining breast is required. If the initial surgery was a bilateral mastectomy, only the clinical and other radiologic assessments, as described above, are required.

Reason for change: To clarify that appropriate radiological imaging must be performed if certain laboratory tests have values outside of the normal range and that mammograms are not applicable for women with bilateral mastectomy.

9. Have undergone either total mastectomy OR lumpectomy;

Reason for change: To clarify that a subject may have undergone a partial mastectomy.

11. May continue to receive endocrine therapy, including tamoxifen or an aromatase inhibitor, while taking study medication, if endocrine therapy was initiated as either adjuvant therapy for treatment of the initial diagnosis of invasive breast cancer or for ovarian function suppression; however, endocrine therapy may not be initiated while taking study medication. Endocrine therapy agents may be switched while participating in this study (e.g., stop tamoxifen and start letrozole);

Reason for change: To allow subjects, who are concomitantly receiving endocrine therapy, to change hormonal agents as determined by their treating physician.

20. Have an archived tumor tissue sample available for biomarker analysis. It is preferable that a paraffin-embedded tissue block from an archived tumor tissue from the primary tumor be submitted. However, for sites that do not allow submission of tumor blocks, it is recommended fifteen (15) twenty (20) slides of paraffin-embedded tissue be submitted instead;

Reason for change: Given the scope of the testing (required and optional) on archived tumor tissue (i.e., confirmation of ErbB2 and hormone receptor status, and biomarker and genetic research objectives), the recommended number of slides was increased.

24. …

• Child-bearing potential (i.e., women with functioning ovaries and no documented impairment of oviductal or uterine function that would cause sterility.) This category includes women with oligomenorrhea (severe), women who are perimenopausal, and young women who have begun to menstruate. These subjects must have a negative serum pregnancy test at screening and agree to one of the following:

• Complete abstinence from intercourse or consistent and correct use of one of the following acceptable methods of birth control from 2 weeks prior to administration of the first dose of study medication until 28 days after the final dose of study medication:

• Consistent and correct use of one of the following acceptable methods of birth control:

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• male partner who is sterile prior to the female subject's entry into the study and is the sole sexual partner for that female subject;

• implants of levonorgestrel, where not contraindicated for this patient population or per local practice;

• injectable progestogen, where not contraindicated for this patient population or per local practice;

• any intrauterine device with a documented failure rate of less than 1% per year;

• oral contraceptives (progestogen only), where not contraindicated for this patient population or per local practice; or

• barrier methods, including diaphragm or condom with a spermicide

Reason for change: Given that some standard clinical practices do not include the use of certain methods of birth control, the text was modified. In addition, the time period during which birth control is required was defined.

6. Section 5.2.2. Exclusion Criteria # 5 and #14 5. Had prior therapy with an ErbB1 and/or ErbB2 inhibitor; women who

experienced a hypersensitivity or allergic reaction to trastuzumab during the first infusion and were unable to complete this infusion are eligible;

Reason for change: To allow inclusion of women in whom the first trastuzumab infusion was incomplete due to allergic reaction; thereby, providing them the opportunity to potentially benefit from treatment with an ErbB2 inhibitor.

14. Receive concurrent treatment with an investigational agent or participate in another clinical trial; ;women, who are in follow-up in another clinical trial where the primary endpoint has been met and the interval between assessments is ≥12 months and radiological imaging is not required at these assessments, are eligible;

Reason for change: To allow subjects who are participating in clinical trials not administering active agents (e.g., quality of life study) or are in the follow-up phase of a clinical trial to participate in this study.

7. Section 6.1 Demographic and Baseline Assessments

The following baseline demographic evaluations should be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Demographic data: date of birth, race geographic ancestry, gender, height, body weight, and menopausal status, and obstetrical history;

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The following baseline safety evaluations must be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Physical examination: vital signs (blood pressure, body temperature, and heart rate) and ECOG performance status (refer to Section 14.4, Appendix 4);

• Cardiac evaluation (refer to Section 6.2.3) by electrocardiogram (12-lead ECG) and echocardiogram or MUGA. Echocardiogram will be performed to evaluate LVEF. If echocardiogram cannot be performed or if the investigator feels it is not conclusive to evaluate LVEF, then a MUGA scan should be done; however, the same method of cardiac evaluation must be used consistently throughout the study;

Reason for change: Obstetrical history was determined not to be an important prognostic factor for this patient population. ‘Geographic ancestry’ is consistent with terminology used on the eCRF. Additional informational regarding cardiac monitoring was added; therefore, an additional section was added.

8. Section 6.2. Safety, Section 6.3. Efficacy, and Section 6.4. Health Outcomes 6.2. Safety

The specific details for timing of all safety assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, safety assessments may be performed up to 7 days before the scheduled visit to the site. To further facilitate scheduling, cardiac evaluation by echocardiogram or MUGA may be performed up to 14 days before or after the scheduled visit to the site. Any assessment may be performed more frequently if clinically indicated.

Section 6.3. Efficacy

Women must have no clinical or radiographic evidence of disease at the time of study entry. The specific details for timing of all clinical outcome assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, efficacy assessments may be performed up to 7 days before the scheduled visit to the site. To further facilitate scheduling, mammography may be performed up to 14 days before or after the scheduled annual test. Any assessment may be performed more frequently if clinically indicated.

Section 6.4. Health Outcomes

The SF-36 will be completed at baseline (prior to administration of first dose of study drug) and prior to any other study procedures, including physician interaction. During the study treatment period, the SF-36v2 will be completed every 6 months (i.e., at Month 6 and Month 12). After withdrawal from study drug, the SF-36v2 will be completed every 6 months for 24 months. The timing of health-related QoL assessment is provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, health-related QoL assessments may be performed up to 7 days before the scheduled visit to the site.

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Reason for change: Visit window specified for 3-monthly visits and for the annual mammography during the treatment phase and for the follow-up phase of the study.

9. Section 6.2.3. Cardiac Assessment 6.2.3. Cardiac Assessment

The following cardiac evaluations must be performed at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1:

• Cardiac evaluation by electrocardiogram (12-lead ECG) and echocardiogram or MUGA. Echocardiogram will be performed to evaluate LVEF. If echocardiogram cannot be performed or if the investigator feels it is not conclusive to evaluate LVEF, then a MUGA scan should be done; however, the same method of cardiac evaluation must be used consistently throughout the study;

• Echocardiogram will be performed under the supervision of an experienced cardiologist, presumably at the same high-volume laboratory for the duration of the study. The guidelines of the American Society of Echocardiography (ASE) should be considered (refer to the SRM for ASE recommendations for the use of echocardiogram in clinical trials);

• Cardiac evaluation by echocardiogram or MUGA will be performed at screening, at Months 3, 6, 9, and 12 during the treatment period and between 6 to 9 months after discontinuation of study drug on all women. Subjects who develop clinical signs or symptoms of cardiac failure should undergo a cardiac evaluation by 12-lead ECG and echocardiogram or MUGA.

Cardiac safety will also be monitored by applying an algorithm for the continuation or discontinuation of study drug according to LVEF assessment (refer to Figure 2 in Section 7.2.2.1).

6.2.3.1. Definitions and Cardiac Monitoring

A cardiac event will be classified as a primary or secondary cardiac endpoint if the event meets the criteria as defined herein.

6.2.3.1.1. Primary Cardiac Endpoints

• Cardiac death defined as either:

• Cardiac death due to heart failure, myocardial infarction or arrhythmia or;

• Probable cardiac death defined as sudden, unexpected death within 24 hours of a definite or probable cardiac event.

• Severe symptomatic congestive heart failure (CHF) defined as:

• New York Heart Association (NYHA) Class III (not capable of climbing one flight of stair) or Class IV (having symptoms at rest) AND an absolute decrease in LVEF of more than 10 percentage points from baseline AND to an LVEF value below 50%.

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NOTE: a second LVEF assessment is NOT needed to confirm the event. However, if a subject experiences severe symptomatic CHF as defined above, cardiac evaluation by echocardiogram or MUGA must be performed every 4 weeks for at least 16 weeks or until resolution.

6.2.3.1.2. Secondary Cardiac Endpoint

• Asymptomatic or mildly symptomatic cardiac event defined as:

• NYHA Class I (asymptomatic) or NYHA Class II (mildly symptomatic) significant decrease in LVEF defined as an absolute decrease in LVEF of more than 10 percentage points from baseline AND to an LVEF value below 50%.

NOTE: a second LVEF assessment must be performed within approximately three weeks to confirm the significant decrease in LVEF as defined above. If a subject has a confirmed secondary cardiac event as defined above, cardiac evaluation by echocardiogram or MUGA must be performed every 4 weeks for at least 16 weeks or until resolution.

6.2.3.2. Stopping and Holding Rules

• If an absolute difference of more than 4% increase in the incidence of primary cardiac endpoints is observed on the lapatinib treatment arms compared with placebo, the Independent Data Monitoring Committee (IDMC) will consider recommending stopping or modifying the trial.

• Rationale for the >4% stopping rule: the incidence of NYHA Class III or IV CHF or possible/probable cardiac death among patients treated with adjuvant trastuzumab in the NSABP-B 31 trial was 4.1%; this was the highest recorded incidence of trastuzumab-associated CHF in any of the recently reported adjuvant trastuzumab breast cancer trials (refer to Table 3) [Romond, 2005].

• If a subject experiences a primary cardiac event, then study drug will be permanently discontinued. If a subject experiences an asymptomatic or mildly symptomatic cardiac event, the decision to continue or discontinue study drug is based on the algorithm in Figure 2 in Section 7.2.2.1.

6.2.3.3. Treatment

It is strongly recommended that subjects who experience a symptomatic decrease in LVEF or meet the criteria for permanently discontinuing study drug seek cardiologic consultation for potential treatment for cardiac dysfunction.

Reason for change: In the adjuvant lapatinib clinical program, the definitions and monitoring of cardiac events had been modified to allow for findings that would be more comparable to results in oncology clinical trials of other targeted agents. Therefore, the cardiac assessment in this protocol was changed to be consistent with the overall development plan for lapatinib as adjuvant treatment of breast cancer.

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10. Section 6.3.1. Clinical Outcome Assessment

• Radiologic assessment:

• Bone scan to include evaluation of skull, total spine, clavicle, ribs, pelvis, and long bones (only required if bone fraction of ALP ≥2 × ULN and/or symptoms suggestive of disease recurrence are present);

• Chest CT scan or MRI scan to include the entire liver, or alternatively, separate chest and abdominal CT (or MRI) scans [(only required if AST, ALT or ALP ≥2 × ULN (not in unless the elevation of ALP is in the bone fraction), and/or symptoms suggestive of disease recurrence are present)];

• Bilateral mammography (unilateral for patients with mastectomy and not applicable for patients with bilateral mastectomy) (only required if not performed within 12 months prior to study entry);

Reason for change: Text was modified for clarity and consistency within protocol.

11. Section 7.2. Dosage and Administration

Section 7.2.1. Lapatinib or Placebo

Subjects will be carefully instructed by study staff as to how to take study drug. A daily dose of study drug (lapatinib or placebo) is six tablets (1500mg of lapatinib) taken approximately at the same time each day. Subjects will be instructed to take study drug either 1 hour (or more) before a meal or 1 hour (or more) after a meal (for example, 1 hour before or after breakfast each day). If a subject misses the prescribed daily dose of study drug and it is more than 6 hours from the time the study drug was scheduled to be taken, the subject should not take that daily dose and resume taking the daily dose at the next scheduled time (that is, the following day).

Reason for change: To provide instruction for missed daily dose of study drug.

Section 7.2.2. Dose Adjustments

Subjects will be treated for a maximum of 1 year (52 weeks) or until disease recurrence or withdrawal from study treatment due to unacceptable toxicity or consent withdrawal. Prior to the beginning At each 3-month course of therapy, subjects will be evaluated for evidence of study drug-related (lapatinib or placebo) toxicity. Results of laboratory assessments should be reviewed as soon as they are available following each 3-monthly visit. If study drug-related toxicity is observed or suspected, the subject may need to be contacted or return to the site for further evaluation or modification to study drug administration.

Reason for change: To clarify the evaluation of laboratory-related toxicity at each 3-monthly study visit.

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Throughout the study, the criteria in Table 7 will be used to modify the study drug administration according to toxicity. Figure 2 in Section 7.2.2.1 provides specific details on criteria used to modify the study drug administration according to asymptomatic or mildly symptomatic cardiac events.


Toxicity Action to be taken1 Hematologic absolute neutrophil count <1.0 × 109/L Delay until resolved to

CTCAE Grade 0 or 1 platelets <50 × 109/L hemoglobin <7.0 g/dL (after transfusion if needed) Standard Chemistry2 unresolved CTCAE Grade 3 or 4 toxicity (except bilirubin and creatinine)

Delay until resolved to CTCAE Grade 0 or 1

bilirubin ≥ 2 X ULN (unless bilirubin was higher at study entry and has not yet reached < 2 X ULN) serum creatinine ≥ 2 X ULN OR calculated creatinine clearance ≤ 20 mL/min3 Non-hematologic any CTCAE Grade 3 or 4 toxicity (except interstitial pneumonitis or left ventricular cardiac dysfunction)

Delay until resolved to CTCAE Grade 0 or 1

CTCAE Grade 3 or 4 interstitial pneumonitis Withdraw study drug CTCAE Grade 3 or 4 left ventricular cardiac dysfunction (symptomatic)

Withdraw study drug

asymptomatic left ventricular cardiac dysfunction Refer to Section 7.2.2.1

CTCAE Grade 1 or 2 diarrhea with complicating features Hold study drug4 3. refer to Section 7.2.2.2 and Section 7.2.2.3 for details on dose delays and dose reductions, respectively. 4. standard chemistry includes albumin, ALP, ALT, AST, BUN, (or urea) calcium, glucose, potassium, sodium,

and total protein. Chemistry evaluation of bicarbonate, chloride, and uric acid are not required where there are logistical constraints.

5. calculate creatinine clearance using standard Cockcroft and Gault method [Cockcroft, 1976; refer to Section 14.5, Appendix 5).

6. refer to Section 7.2.2.4 for supportive care guidelines for diarrhea. Abbreviations: ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; BUN = blood urea nitrogen; CTCAE = common terminology criteria for adverse events; ULN = upper limit of normal

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Toxicity (Graded According to NCI CTCAE) Action to be taken1 Non-hematologic2 CTCAE Grade 1 or 2 (except Grade 1 or 2 diarrhea with complicating features)

Continue study drug • IF prolonged duration (≥2 weeks) of Grade 2 occurs which affects the

subject’s quality of life, reduce study drug to 5 tablets (equivalent to 1250mg QD active drug)

Refer to Supportive Care Guidelines in the SRM for uncomplicated diarrhea and skin toxicities. Refer to Figure 2 for asymptomatic or mildly symptomatic cardiac event

CTCAE Grade 3 or 4 toxicity (except interstitial pneumonitis, Grade 4 rash, or left ventricular cardiac dysfunction) or CTCAE Grade 1 or 2 diarrhea with complicating feature

• CTCAE Grade 3 or 4 interstitial pneumonitis • CTCAE Grade 4 rash manifested as toxic epidermal

necrolysis (i.e., Stevens Johnson’s Syndrome, etc) • CTCAE Grade 3 or 4 left ventricular cardiac dysfunction

(symptomatic)

Delay study drug until resolution to Grade 0 or 1 (up to 2 weeks) • IF recurrence of toxicity (after delaying study drug) occurs, then

reduce to 5 tablets (equivalent to 1250mg QD active drug). • IF toxicity does not resolve to ≤ Grade 2 (within 2 weeks from last

administration), consult with Medical Monitor before continuing therapy.

Discontinue study therapy if Grade 3/4 interstitial pneumonitis or cardiac dysfunction, or Grade 4 Stevens Johnson’s Syndrome. Treatment of these CTCAEs is indicated as clinically appropriate. Refer to Supportive Care Guidelines in the SRM for diarrhea and skin toxicities

Hematologic absolute neutrophil count <1.0 × 109/L platelets <50 × 109/L hemoglobin <7.0 g/dL (after transfusion if needed)

Delay study drug until resolved to CTCAE Grade 0 or 1 (up to 2 weeks)

1. refer to Section 7.2.2.2 and Section 7.2.2.3 for details on dose delays and dose reductions, respectively; 2. includes chemistry-related toxicity and all other non-laboratory toxicity; Abbreviations: CTCAE = common terminology criteria for adverse events; QD = once daily; SRM = Study Reference Manual. [National Cancer Institute, 2005]

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Reason for change: To provide comprehensive criteria for modifying study drug administration due to study drug-related toxicity

Section 7.2.2.1. Criteria for Evaluating Asymptomatic or Mildly Symptomatic Cardiac Events

If a subject experiences a ≥20% decrease in LVEF relative to baseline AND the LVEF is below the institution's lower limit of normal (LLN), another evaluation of LVEF must be performed 2 weeks later while still receiving study drug.

Upon completion of the first repeat evaluation of LVEF, the procedures described in Table 8 must be followed:

Table 8 Criteria for Continuing Study Drug Following First Repeat Cardiac Evaluation Performed 2 Weeks Later While Still Receiving Study Drug

Institution’s Range

LVEF Relative Change From Baseline

Action to be Taken

below LLN ≥20% temporarily withdraw study drug

repeat cardiac evaluation in 2 wks & follow procedures in Table 9 below LLN <20% reduce to 4 tablets (equivalent to 1000mg QD active drug)

repeat cardiac evaluation in 2 wks & follow procedures in Table 10

WNL ≥20% continue study drug

repeat cardiac evaluation in 2 wks & follow procedures in Table 11

WNL <20% continue study drug continue cardiac evaluation every 3 months; refer to Time & Events Table, Section 14.1, Appendix 1

Abbreviations: LLN = lower limit of normal; LVEF = left ventricular ejection fraction; WNL = within normal limits

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Table 9 Criteria for Continuing Study Drug Following Second Repeat Cardiac Evaluation



Action to be Taken

below LLN ≥20% permanently withdraw study drug

repeat cardiac evaluation every 4 wks for at least 16 wks or until resolution

below LLN <20% permanently withdraw study drug


WNL ≥20% permanently withdraw study drug


WNL <20% reduce to 4 tablets (equivalent to 1000mg QD active drug) continue cardiac evaluation every 3 months; refer to Time & Events Table, Section 14.1, Appendix 1

Abbreviations: LLN = lower limit of normal; LVEF = left ventricular ejection fraction; WNL = within normal limits Table 10 Criteria for Continuing Study Drug Following Second and Subsequent Repeat Cardiac Evaluations



Action to be Taken





WNL ≥20% permanently withdraw study drug


WNL <20% continue at reduced dose continue cardiac evaluation every 3 months; refer to Time & Events Table, Section 14.1, Appendix 1

Abbreviations: LLN = lower limit of normal; LVEF = left ventricular ejection fraction; WNL = within normal limits

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Table 11 Criteria for Continuing Study Drug Following Second Repeat Cardiac Evaluation



Action to be Taken





WNL ≥20% continue study drug continue cardiac evaluation every 3 months; refer to Time & Events Table, Section 14.1, Appendix 1

WNL <20% continue study drug continue cardiac evaluation every 3 months; refer to Time & Events Table, Section 14.1, Appendix 1

Abbreviations: LLN = lower limit of normal; LVEF = left ventricular ejection fraction; WNL = within normal limits NOTE: If following a dose reduction, a subject experiences a ≥20% decrease in LVEF relative to baseline OR the LVEF is below the institution's LLN, the subject will be permanently withdrawn from study drug and cardiac evaluations must be performed every 4 weeks for at least 16 weeks or until resolution.

A ≥ 20% relative decrease from baseline in LVEF (asymptomatic or symptomatic), that is below the institution’s LLN is considered an SAE and must be reported to GSK (refer to Section 10.2 for definition of an SAE).

Subjects who experience an asymptomatic or mildly symptomatic decrease in LVEF from baseline must be treated according to the algorithm depicted in Figure 2.

NOTE: Subjects with NYHA Class III or IV CHF must permanently discontinue study drug upon diagnosis and seek cardiology consultation.

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Figure 2. Algorithm for continuation or discontinuation of study drug based on interval LVEF assessments

LVEF drop

HOLD study drug and


LVEF <50 %




LVEF drop≤10% points


REPEAT LVEF as per protocol1


REPEAT LVEFin 3 weeks2

LVEF <50% and


LVEF <50%and


DISCONTINUEstudy drug3

RESUME study drug

and REPEAT LVEF

in 3 weeks

LVEF ≥50%

LVEF ≥50% and

LVEF drop >10%or ≤10% points

REDUCE study drug to

4 tablets and


1. Cardiac evaluation by echocardiogram or MUGA should recommence at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1. 2. If upon repeat LVEF evaluation the LVEF drop and LVEF value are the same as the previous evaluation, then call the Medical Monitor. 3. Cardiac evaluations by echocardiogram or MUGA must be performed every 4 weeks for at least 16 weeks or until resolution.

If a secondary cardiac event is confirmed, then study drug will be permanently discontinued (shaded pathway in Figure 2). If following a dose reduction for a cardiac event, a subject experiences an absolute decrease in LVEF of more than 10 percentage points from baseline AND to an LVEF value below 50%, then study drug will be permanently discontinued. In subjects who permanently discontinue study drug, cardiac evaluations must be performed every 4 weeks for at least 16 weeks or until resolution.

Reason for change: In the adjuvant lapatinib clinical program, the definitions and monitoring of cardiac events had been modified to allow for findings that would be more comparable to results in oncology clinical trials of other targeted agents. Therefore, the cardiac assessment in this protocol was changed to be consistent with the overall development plan for lapatinib as adjuvant treatment of breast cancer.

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Section 7.2.2.2. Dose Delays

Administration of study drug may be delayed (according to criteria in Table 7) up to 2 weeks to allow for resolution of toxicity except in the event of NCI CTCAE Grade 3 or 4 left ventricular cardiac dysfunction, or NCI CTCAE Grade 3 or 4 interstitial pneumonitis, or NCI CTCAE Grade 4 rash manifested as toxic epidermal necrolysis [National Cancer Institute, 2005]. The investigator must consult the GSK Medical Monitor prior to continuing therapy for any subject requiring a delay of more than 2 weeks for unresolved toxicity, but in general, such subjects should be withdrawn from the study. If treatment is delayed for reasons other than toxicity (i.e., unplanned travel or vacation, or lack of transportation to the site) and the subject has insufficient study drug available, the subject should resume the usual dosing schedule once drug supply has been made available. However, if the subject has been off therapy for more than 2 weeks, the investigator must consult the GSK Medical Monitor prior to continuing therapy.

Section 7.2.2.3. Dose Reductions

Dose reduction for drug-related toxicity is permitted (according to criteria in Table 7) however the GSK Medical Monitor must be consulted prior to implementing any change in dosing. Dose escalation is not permitted; therefore, subjects should not be re-challenged to a higher dose level. If a NCI CTCAE Grade 3 or 4 drug-related event (other than left ventricular cardiac dysfunction or interstitial pneumonitis) has occurred, the investigator may discuss with the GSK Medical Monitor whether a reduction of dose is appropriate.

Reason for change: Text modified for consistency with amended Table 7.

7.2.2.4. Supportive Care Guidelines for Diarrhea

If a subject experiences uncomplicated Grade 1-2 diarrhea, the guidelines described herein should be followed:

• Stop all lactose containing products; • Drink 8-10 large glasses of clear liquids a day; • Eat frequent small meals; • Grade 2 diarrhea consider dose reduction of lapatinib (discuss with GSK

Medical Monitor); • Administer standard dose of loperamide:

• Initial dose 4mg followed by 2mg every 4 hours or after every unformed stool.

• Continuation of loperamide suggested until diarrhea free for 12 hours.

If a subject experiences Grade 3 or 4 diarrhea or Grade 1 or 2 with complicating features (severe cramping, severe nausea/vomiting, decreased performance status, fever, sepsis, Grade 3 or 4 neutropenia, frank bleeding, dehydration), the guidelines described herein should be followed:

• Use intravenous fluids as appropriate, consider hospital admission;

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• Use prophylactic antibiotics as needed (example fluoroquinolones), especially if diarrhea is persistent beyond 24 hours or there is fever or Grade 3 or 4 neutropenia;

• Hold study drug and discuss with GSK Medical Monitor.

These broad general management principles are recommended to proactively try and avoid more serious complications by active management of the diarrhea syndrome. Guidelines such as these should never replace sound clinical judgment. Experience thus far suggests that when lapatinib is used as monotherapy, most diarrheas are uncomplicated Grade 1 or 2. These general management principles do not discuss comprehensive management of more serious or protracted diarrhea syndromes.

Reason for change: Supportive care guidelines were moved into the SRM.

12. Section 7.9. Assessment of Compliance

A record of the number of tablets dispensed to and taken returned by each subject must be maintained and reconciled with the 'Investigational Product' field in the eCRF. documented in the Drug Dispensing Log for each subject. The estimate of percent compliance will be calculated as:

*number of days in visit interval = (date returned — date dispensed) +1 in visit interval.

The number of tablets prescribed per day will be calculated using the assigned dose from the IP form in the eCRFs. The expected number of tablets to be taken daily is 6 tablets (250mg each); however, any investigator-prescribed dose adjustments, such as, withdrawing study drug or reducing dose, will be taken into account. Refer to the Study Drug Management document in the SRM for details on these calculations.

NOTE: subjects who are instructed by the investigator to withdraw study drug (for example, due to an adverse event) will not be considered non-compliant. The number of days in this interval where study drug was withdrawn will be excluded from the compliance calculation (i.e., excluded from the number of days in the visit interval).

Compliance with dosing will be assessed through querying the subject during the site visits and the percent compliance will be documented in the source documents and recorded in the eCRF. The investigator’s judgment of compliance will be accepted. Subjects should be instructed to record any missed doses of investigational product.

Reason for change: To provide details on how compliance with study drug administration will be defined and calculated.

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13. Section 8. Concomitant Medications and Non-Drug Therapies

Section 8.2. Prohibited Medications

Investigational drugs are not permitted from 34 weeks (2130 days) or 5 half-lives, whichever is longer, prior to the first dose and up through 30 days after the last dose of investigational product;

Reason for change: Text modified for consistency with Exclusion Criterion #16 which does not allow subjects who have used an investigational drug within 30 days of the first dose of study medication.

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Table 8. Prohibited Medications

Drug Class Agent Wash-out1 CYP3A4 Inducers Antibiotics all rifamycin class agents (e.g., rifampicin,

rifabutin, rifapentine) 14 days Anticonvulsants phenytoin, carbamazepine, barbiturates (e.g.,

phenobarbital) Antiretrovirals efavirenz, nevirapine Glucocorticoids (oral) cortisone (>50 mg), hydrocortisone (>40 mg),

prednisone (>10 mg), methylprednisolone (>8 mg), dexamethasone (>1.5 mg)2

Other St. John’s Wort, modafinil CYP3A4 Inhibitors Antibiotics clarithromycin, erythromycin, troleandomycin

7 days Antifungals itraconazole, ketoconazole, fluconazole (>150 mg daily), voriconazole

Antiretrovirals, Protease Inhibitors

delaviridine, nelfinavir, amprenavir, ritonavir, indinavir, saquinavir, lopinivir, atazanivir

Calcium channel blockers verapamil, diltiazem Antidepressants nefazodone, fluvoxamine GI Agents cimetidine, aprepitant Other grapefruit, grapefruit juice

amiodarone 6 months

Miscellaneous Antacids Mylanta, Maalox, Tums, Rennies 1 hour before and

after dosing Herbal supplements3 Ginkgo biloba, kava, grape seed, valerian,

ginseng, echinacea, evening primrose oil. 14 days

1. At the time of screening, if a patient is receiving any of the above listed medications/substances, the medication or substance must be discontinued (if clinically appropriate) for the period of time specified prior to administration of the first dose of study drug and throughout the study period in order for the patient to be eligible to participate in the study.

2. Glucocorticoid daily doses (oral) ≤ 1.5 mg dexamethasone (or equivalent) are allowed. Glucocorticoid conversions are provided in parentheses.

3. This list is not all-inclusive; therefore, for herbal supplements not listed, please contact the GSK Medical Monitor or Clinical Scientist.

NOTE: if future changes are made to the list of prohibited medications, a formal documentation will be created and stored with the study file. Any changes will be communicated to the investigative sites in the form of a letter.

Reason for change: antiretroviral was added for completeness

Section 8.3. Non-Drug Therapies

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Concurrent surgery as cancer therapy and radiotherapy (unless initiated as adjuvant therapy for treatment of the initial diagnosis of invasive breast cancer) is prohibited during randomized therapy.

Reason for change: To clarify that only surgeries intended as treatment of cancer are prohibited.

14. Section 10. Adverse Events (AE) and Serious Adverse Events (SAE)

Section 10.1. Definition of an AE

Any untoward medical occurrence in a patient or clinical investigation subject, temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product.

NOTE: An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally associated with the use of a medicinal product. For marketed medicinal products, this also includes failure to produce expected benefits (i.e. lack of efficacy), abuse or misuse.

Symptomatic declines in LVEF that do not meet the criteria for a secondary cardiac endpoint (e.g. an absolute decrease in LVEF of ≤10 percentage points from baseline and to an LVEF value <50% OR an absolute decrease in LVEF of >10 percentage points from baseline and to an LVEF value of ≥50%) are not expected to be common. These events should be reported as AEs or SAEs, if applicable, as described below. Asymptomatic declines in LVEF that do not meet the criteria for ‘significant’, as defined in Section 6.2.3.1.2, do not qualify as a secondary cardiac endpoint and will not be reported as AEs.

Section 10.2. Definition of an SAE

Additional protocol-defined criteria

• All Grade 4 laboratory abnormalities.

Cardiovascular events have been seen in subjects taking other compounds that inhibit ErbB2 when used in combination with or following anthracyclines and interstitial pneumonitis has been reported in subjects taking compounds that inhibit ErbB1. As a precaution, the following will be reported as an SAE:

• Primary cardiac endpoints (severe symptomatic CHF and cardiac death).

NOTE: If a secondary cardiac endpoint fulfills any of the criteria for ‘seriousness’ (e.g. hospitalization), it must also be reported as an SAE. Cardiac dysfunction will be reported as an SAE and will be defined as any signs or symptoms of deterioration in left ventricular ejection fraction (LVEF) that are Grade 3 or 4 (NCI CTCAE) or a ≥ 20% relative decrease in LVEF from baseline which is also below the institution's LLN. Refer to NCI CTCAE grading of left ventricular cardiac function.

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• Any signs or symptoms of pneumonitis that are ≥Grade 3 (NCI CTCAE) (defined as radiographic changes and requiring oxygen). Refer to NCI CTCAE grading of pneumonitis/pulmonary infiltrates [National Cancer Institute, 2005].

Reason for change: Text regarding cardiac events was modified for consistency within the protocol.

Section 10.6. AE and SAE Documentation and Follow-up Procedures

The investigator will review and adhere to the following procedures, which are outlined in detail in the AE/SAE section of the SRM:

• Method of Detecting AEs and SAEs

• Recording of AEs and SAEs

• Evaluating of AEs and SAEs

• Completion and Transmission of SAE Reports to GSK

• Follow-up of AEs and SAEs

• Post-study AEs and SAEs

• Reporting new SAEs or updated SAE data after the electronic data collection tool has been taken off line.

• Regulatory Reporting Requirements for SAEs

Reason for change: Text added for consistency with sections in the SRM.

15. Section 11. Data Analysis and Statistical Considerations

11.2.1. Sample Size Assumptions

A maximum of 4639 subjects with disease recurrence will be required. To achieve this number, an estimated total of 3000 (2875+125) subjects would need to be enrolled, leading to an estimated maximum study duration of 37 months.

11.2.2. Sample Size Sensitivity

Table 10 shows, for various hazard ratios for DFS, the power to detect superior survival in the lapatinib arm (1-sided p ≤ 0.025) at the interim analysis and overall (at either the interim or by the final analysis of DFS).

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Table 10 Power to Detect Superiority of Lapatinib Versus Placebo Disease-Free Survival

Hazard Ratio Power to Detect Superiority of Lapatinib, % Lapatinib/Placebo Interim Analysis Overall

1.00 0.60.001 2.5 0.80 299 66 0.769 4216 80 0.70 7343 97 0.67 8460 99

11.3.3. Interim Analysis

A maximum of two analyses (an interim analysis and a final analysis) of DFS will be performed. The interim analysis will occur when two-thirds of the total number of required events have occurred (i.e., at 30913 events). The final analysis will take place when 4639 events have occurred.

The interim analysis is estimated to occur after about 28 months from the time the first subject is enrolled. A Haybittle-Peto Lan-DeMets implementation of O'Brien & Fleming stopping boundariesy with a one-sided 2.5% significance level will be used to reject H0

(i.e., support for superior efficacy in the lapatinib arm) [Lan, 1983] [O'Brien, 1979].[Mehta, 2005]. This boundary permits specification of the interim stopping boundary based on a pre-specified p-value, while adjusting the final p-value requirement to satisfy the overall alpha of 0.025 (one-sided). Superiority will be declared for DFS if the log-rank test results in p ≤0.0005 (one-sided). Using a one-sided Type I error, a nominal alpha of 0.00056 will be ‘spent’ at the interim analysis.

An analysis of overall survival data will be performed at the time of the interim analysis. For the IDMC committee to recommend early termination of the trial due to superior efficacy, it would be necessary for there to be a strong trend in survival in addition to having met the stopping criteria for superiority of DFS.

Futility will additionally be assessed at the interim analysis. The 95% confidence interval (CI) will be calculated for the hazard ratio (HR) (Lapatinib/Placebo) for DFS. If the lower boundary of the 95% CI for the HR for DFS is ≥0.885 (the mid-point between 0.769 and 1), then futility of lapatinib will be indicated. The IDMC may consider stopping the study if this criterion is met at the interim analysis.

Safety reviews will take place at 6 monthly intervals, from the initiation of the study. Overall survival (OS) data will be supplied at each 6 monthly safety review, (once there are sufficient deaths to perform this analysis.) If the OS data indicate highly significant evidence for inferiority of Lapatinib, then the IDMC may recommend early termination for the study. However, no specific stopping rule for safety will be defined.

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Reason for change: Following review of the prospectively defined interim and final analyses outlined in the Independent Data Monitoring Committee Charter by the IDMC members, amendments were requested. The stopping boundary defined for the interim analysis was modified to require a more stringent stopping boundary in order for lapatinib to be declared superior for the primary variable, DFS. Furthermore, a requirement for a significant trend in survival data was added to support any IDMC decision to discontinue the study due to superiority. For the assessment of futility at the formal interim analysis, guidance, in the form of a predefined criteria based around the 95% confidence interval for the hazard ratio for DFS, was specified.

16. Section 6.2.2.1. Time Period for Collecting Pregnancy Information and Section 10.4. Time Period, and Frequency of Detecting AEs and SAEs

Section 6.2.2.1

The time period for collecting pregnancy information is identical to the time period for collecting AEs, as stated in Section 10.4. Pregnancy information is collected from the first dose of study drug to 30 5 days after the last dose.

Section 10.4

From the time a subject consents to participate in the study until she has completed the study (including any follow-up period), all SAEs assessed as related to study participation (e.g., protocol-mandated procedures, invasive tests, or change in existing therapy) or related to a GSK concomitant medication, will be reported promptly to GSK.

All AEs and SAEs regardless of relationship to study drug will be collected from the first dose of study drug to 30 5 days after the last dose and recorded on the eCRF.

Subjects will be monitored at each scheduled assessment at the site (approximately every 3 months during treatment), at any contact with the subject during the study, and at the withdrawal visit, for the occurrence of AEs/SAEs. The investigator or designee will inquire about the occurrence of AEs/SAEs at every visit/contact during the study and throughout the 30 5 days following cessation of treatment by asking the following standard questions:

Reason for change: It is required to collect adverse events and pregnancies for 5 half lives post last dose. Since the half life for lapatinib is 24 hours, 30 days was changed to 5 days in these sections.

16. Section 14.1. Appendix 1. Time & Events Table and Title Page and Protocol Summary section

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The Time and Events Table has been updated to:

• Clarify that a mammograpy is required every 12 months during the treatment and the follow-up phases of the study;

• Clarify research to be performed on the archived tumor tissue sample and tumor tissue biopsy at the time of disease recurrence;

• Clarify screening laboratory values for consistency within the protocol;

• Clarify efficacy assessments for consistency within the protocol;

• Clarify administration of study drug for consistency within the protocol.

The Title page and Protocol Summary Section have been updated to:

• Clarify research to be performed on the archived tumor tissue sample and tumor tissue biopsy at the time of disease recurrence;

• Clarify study population for consistency within the protocol.

17. Section 14.3. Appendix 3. American Joint Committee on Cancer Staging Criteria

Reason for change: a more detailed and complete version of the AJCC (6th Edition) was added.

18. Section 14.5. Appendix 5. Cockcroft and Gault Method for Calculated Creatinine

Creatinine clearance can be calculated from serum creatinine values by one of the two formulas below:


(140 − age [yrs] ) × weight (kg) 72 × serum creatinine (mg/DL)

Female patients: multiply by 0.85 In order to use SI units for creatinine (µmol/L), the following formula may be used.


(140 − age [yrs] ) × weight (kg) x 1.23 88.4 72 × 1 × serum creatinine (µmol/L))

Female patients: multiply by 0.85

Reason for change: Values changed to reflect the calculation logic performed sequentially by the central laboratory.

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Amendment 5 Changes

The global Protocol Amendment No. 02 date, 31 January 2007, is replaced by Protocol Amendment No. 05, 21 May 2008. This amendment applies to all global participating investigative sites.

Protocol Amendment No. 03 date, 20 June 2007, was a country-specific Companion Protocol written to encompass the biomarker, proteomic, and pharmacogenetic research objectives for Study EGF105485 in accordance with Brazilian Regulations and was only applicable in Brazil.

Protocol Amendment No. 04 date, 29 June 2007, was a Sub-Study Protocol written with the intention to characterize the effects of lapatinib on the corrected QT (QTc) interval in women with early-stage ErbB2-overexpressing breast cancer and to contribute to the comprehensive cardiac safety data for lapatinib. Selected investigative sites participated in this sub-study.

The following protocol changes (items #1-5) have been implemented following a review of all hepatobiliary events reported across the entire lapatinib clinical development programme. This analysis was performed as part of of ongoing pharmacovigilance by GlaxoSmithKline. Two hundred sixteen reports of hepatic events were retrieved from the GSK safety database as of 31 December 2007 regardless of source [clinical trials (N=8702 lapatinib-treated patients) and spontaneous/marketed use data]. In 39 of the 216 cases, a causal association to lapatinib could not be ruled out: 38.5% (15/39) of these subjects received lapatinib monotherapy, 53.8% (21/39) of subjects received lapatinib in combination with other chemotherapies, such as capecitabine, and 3 cases were still blinded.

A total of 13 deaths were identified which contained hepatobiliary events. In 3 of these cases, an association with lapatinib could not be excluded. The remaining 10 cases were confounded by the patients underlying condition (progressive disease and/or progression of pre-existing liver metastases).

Based on an additional sub-analysis, of 18 clinical studies of lapatinib in breast cancer, using Hy’s Law (defined as AST or ALT >3 × ULN, and total bilirubin >2 × ULN, with no initial findings of cholestasis i.e.: ALP <2 × ULN) as a predictor for potential drug induced liver injury, the liver injury associated with lapatinib seems to be the result of a prolonged exposure to the drug. All the subjects whose events potentially met Hy’s Law received study medication for three months or longer. The majority of these cases appeared reversible. Most patients experienced a decline in liver enzymes with drug cessation.

Based on the results of this review, GSK concluded a causal relationship between hepatobiliary disorders (specifically transaminase elevations) and lapatinib cannot be excluded. As a consequence, hepatotoxicity was added to the core safety information (CSI) for lapatinib. In addition, for ongoing clinical trials, protocols were amended to increase the monitoring interval for hepatic function and stopping rules were added for severe hepatic events.

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1. Protocol Summary/Study Assessments and Section 6.2.1. Laboratory Assessment

PROTOCOL SUMMARY

Study Assessments

Efficacy will be evaluated through clinical assessment (medical history, physical examination, and evaluation of other signs and symptoms that may be suggestive of disease recurrence or a second primary cancer). Radiological imaging (chest x-ray, CT scan, or MRI, bone scan, and/or head MRI, if applicable) and histological and/or cytological biopsies (if applicable) will be performed when symptoms suggest disease recurrence or a second primary cancer and at the discretion of the investigator. Clinical assessments will be performed every 3 months while on study therapy, with the exception of standard chemisty which will be performed every 6 weeks or more frequently if clinically indicated while on study therapy to monitor liver function.

6.2.1. Laboratory Assessment

Table 6 Laboratory Assessments

Hematology Standard Chemistry1 hemoglobin sodium hematocrit potassium red blood cell count calcium platelets glucose white blood cell count with differential blood urea nitrogen or urea total neutrophils creatinine2 lymphocytes AST monocytes ALT eosinophils alkaline phosphatase basophils total bilirubin4 total protein albumin Serum Pregnancy3 serum β-hCG (human chorionic gonadotrophin) 1. chemistry evaluation of bicarbonate, chloride, and uric acid are not required where there are logistical constraints 2. if serum creatinine is >2.0 mg/dL, calculate creatinine clearance using standard Cockcroft and Gault method (refer

to Section 14.5, Appendix 5) [Cockcroft, 1976]. 3. refer to Section 6.2.2 for further details on serum pregnancy testing. 4. bilirubin fractionation is recommended if total bilirubin >2 × ULN when testing is available

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Prior to administration of the first dose of study drug, results of laboratory assessments should be reviewed. Any laboratory test with a value outside the normal range will be repeated (prior to the first dose) at the discretion of the investigator. Before the first dose of study drug, all laboratory results must be within the values outlined in Section 5.2.1, Table 5). All laboratory tests with values that are significantly abnormal during participation in the study or within 30 days after the last dose of study drug should be repeated until the values return to normal or baseline. If such values do not return to normal within a period judged reasonable by the investigator, the etiology should be identified and the sponsor notified. Standard chemistry will be performed every 6 weeks or more frequently if clinically indicated during the study drug treatment phase to allow for close monitoring of liver chemistry results (refer to Section 7.2.2.2 for liver chemistry stopping rules and follow up criteria).

2. Section 7.2.2. Dose Adjustments

Throughout the study, the criteria in Table 7 will be used to modify the study drug administration according to toxicity. Figure 2 in Section 7.2.2.1 provides specific details on criteria used to modify the study drug administration according to asymptomatic or mildly symptomatic cardiac events. Section 7.2.2.2 provides specific details on criteria used to modify the study drug administration according to liver chemistry results and follow up criteria for a liver-related event.

7.2.2.2. Liver Chemistry Stopping Rules and Follow Up Criteria

7.2.2.2.1. Liver Chemistry Stopping Rules

Liver chemistry stopping rules and follow up criteria have been designed to assure subject safety and to evaluate liver event etiologies. All subjects who meet liver chemistry criteria requiring permanent discontinuation of investigational product must continue to be followed for the study assessments and procedures as defined in Section 6 and at the time points indicated in the Time & Events Table in Section 14.1 Appendix 1.

If a subject experiences any of the following: • ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation

required*);

*NOTE: bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the actions detailed below must still be performed.

• ALT ≥5 × ULN; • ALT >3× ULN with signs or symptoms of hepatitis or hypersensitivity (the

appearance or worsening of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or eosinophilia);

• ALT >3 × ULN persisting for ≥4 weeks (subjects with ALT >3 × ULN should be monitored weekly for 4 weeks to determine if ALT elevation persists);

• ALT >3 × ULN and unable to undergo weekly monitoring.

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then the following actions must be taken: • immediately and permanently discontinue investigational product;

• for subjects who have ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation required*), promptly report the event as SAE to GSK within 24 hours of learning its occurrence (refer to Section 10.5 for guidance on prompt reporting to GSK);

• complete the SAE data collection tool for all other subjects only if the event meets the criteria for an SAE;

• complete the liver event eCRF and the liver imaging and/or liver biopsy eCRFs, if these tests are performed;

• monitor every week until liver chemistries resolve, stabilize, or return to within baseline values

• do not re-challenge with investigational product.

If a subject experiences ALT >3 × ULN but <5 × ULN and total bilirubin ≤2 × ULN, without signs or symptoms of hepatitis or hypersensitivity, and who can be monitored weekly, then the following actions should be taken:

• continue investigational product;

• monitor weekly until liver chemistries resolve, stabilize, or return to within baseline, then monitor liver chemistries as per protocol assessment schedule;

• if at any time this subject meets any of the aforementioned liver chemistry stopping rules, then proceed as described above;

7.2.2.2.2. Liver Chemistry Follow Up Criteria

For all subjects who meet any of the liver chemistry stopping rules, make every attempt to carry out the liver event follow up assessments described below:

• Viral hepatitis serology including:

• Hepatitis A IgM antibody;

• Hepatitis B surface antigen and Hepatitis B Core Antibody (IgM);

• Hepatitis C RNA;

• Cytomegalovirus IgM antibody;

• Epstein-Barr viral capsid antigen IgM antibody (or if unavailable, obtain heterophile antibody or monospot testing);

• Hepatitis E IgM antibody (if subject resides or has travelled outside USA or Canada in past 3 months);

• Serum creatine phosphokinase (CPK) and lactate dehydrogenase (LDH);

• Complete blood count with differential to assess eosinophilia;

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• Record the appearance or worsening of clinical symptoms of hepatitis, or hypersensitivity, fatigue, decreased appetite, nausea, vomiting, abdominal pain, jaundice, fever, or rash as relevant on the AE eCRF;

• Record use of concomitant medications, acetaminophen, herbal remedies, other over the counter medications, or putative hepatotoxins, on the concomitant medications eCRF;

• Record alcohol use on the liver event alcohol intake eCRF;

The following assessments are suggested:

• specialist or hepatology consultation;

• anti-nuclear antibody, anti-smooth muscle antibody, and Type 1 anti-liver kidney microsomal antibodies;

• liver imaging and/or liver biopsy to evaluate liver disease;

• additional tests (e.g., pharmacokinetics) may be required.

Figure 3 presents a liver safety algorithm detailing stopping rules and follow up criteria.

Figure 3 Algorithm for Liver Chemistry Stopping Rules and Follow up Criteria

ALT >3 × ULN

Bilirubina >2 × ULN (>35% direct) ALT ≥5 × ULN

signs & symptomsb

of hepatitis orhypersensitivity

Able to monitor liver chemistries

weekly

Continue IP; monitor liver

chemistries weekly for 4 weeks

ALT >3 × ULN persistsfor ≥4 weeks

Continue IP; monitor weekly until

liver chemistries resolve, stabilize, or return to baselinec

• immediately & permanently discontinue investigational product;• complete the SAE eCRF (if applicable); • perform liver event follow up assessments (serologies, etc, as noted in Section 7.2.2.2.2);• complete the liver event CRF, liver imaging and/or biopsy eCRFs, if these tests were done• monitor weekly until liver chemistries resolve, stabilize, or return to baseline;• do NOT re-challenge with investigational product

Report as SAE to GSK within 24 hours

Yes

Yes

No No

Yes Yes No

No

Yes Yes

No

Yes

Yes

IF:

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b. bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the event should still be reported as an SAE and actions taken as described

c. the appearance or worsening of fatigue, nausea, vomiting, right upper quadrant pain or tenderness, fever, rash, or eosinophilia

d. once liver chemistries resolve, stabilize, or return to baseline, then continue monitoring per the protocol assessment schedule

3. Section 9.2.2. Subject Withdrawal from Study Drug

A subject will be considered as withdrawing from study drug if:

• the subject has completed the 12-month treatment period of study drug;

OR

• the subject has prematurely, but permanently, discontinued taking study drug.

The primary reason for withdrawal from study drug, as listed below, must be entered on the ‘Investigational Product Discontinuation’ eCRF page:

• completion of the 12-month treatment period with either lapatinib or placebo;

• AE (including intercurrent illness, unacceptable toxicity);

NOTE: Refer to details regarding liver chemistry stopping rules as specified in Section 7.2.2.2.1.

. 4. Section 10.2 Definition of an SAE, Additional Protocol-defined Criteria and Section 10.5 Prompt Reporting of SAEs to GSK

Additional Protocol-defined Criteria

Hepatobiliary events have been seen in subjects taking lapatinib and other tyrosine kinase inhibitors. As a precaution, the following will be reported as an SAE:

• ALT >3 × ULN and total bilirubin >2.0 × ULN (>35% direct; bilirubin fractionation required).

• NOTE: bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets the criterion of total bilirubin >2.0 × ULN, then the event should still be reported as an SAE.

Other hepatic events should be documented as an AE or an SAE as appropriate.

10.5 Prompt Reporting of SAEs to GSK

Serious adverse events, pregnancies, and liver function abnormalities meeting pre-defined stopping rules will be reported promptly to GSK as described in the following table once the investigator determines that the event meets the protocol definition of an SAE.

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Table 9 Timeframes for Submitting SAE and Pregnancy Reports to GSK

Initial SAE Reports Follow-up Information on a Previously Reported SAE

Type of SAE Time Frame Documents Time Frame Documents All SAEs 24 hours "SAE" data

collection tool 24 hours Updated "SAE"

data collection tool

Pregnancy 2 weeks Pregnancy Notification Form

2 weeks Pregnancy Follow up Form

Liver Chemistry

Abnormalities:

ALT >3 × ULN and bilirubina

>2 × ULN (35% direct)

24 hours Liver Event and Liver Imaging and/or Biopsy

eCRFs, if applicable

24 hours Updated Liver Event eCRF

Abbreviations: GSK = GlaxoSmithKline; SAE = serious adverse events e. bilirubin fractionation should be performed if testing is available. If testing is unavailable and a subject meets

the criterion of total bilirubin >2.0 × ULN, then the event should still be promptly reported as defined 5. Section 14.1. Appendix 1. Time & Events Table

The Time and Events Table has been updated to

• clarify that standard chemistry is required every 6 weeks during the study drug treatment phase of the study;

• clarify the timing of the Early Study Withdrawal/Month 12 Visit

6. Section 4. Study Design

The frequency of efficacy assessments (evaluation of disease status, survival and anti-cancer therapies) in the follow up phase will be determined according to Table 4. However, all safety and health-related QoL assessments in the follow up phase must be performed in all women at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1.

Reason for change: Added text to clarify that all women must complete the safety and health-related QoL assessments at the protocol-defined timepoints regardless of their frequency of efficacy assessments in the follow up phase of the study.

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7. Section 6 Study Assessments

Medical and physical examinations should be performed by a qualified physician and should include a thorough review of all body systems. Relevant data will be captured in the eCRF, as detailed in Section 12.8. All other data will be recorded in source documents. Study-relevant data will be captured in the eCRF and originate from source documentation which is comprised of the study relevant data/assessments as well as the remaining data captured during the medical and physical examination of the subject.

Reason for change: Clarification of subject’s medical data and source documentation.

8. Sections 6.2 Safety, 6.3.1. Clinical Outcome Assessment, and 9.2.2. Subject Withdrawal from Study Drug

6.2. Safety

The specific details for timing of all safety assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, safety assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Safety assessments during the follow up phase may be performed up to 7 days before and up to 7 days after the scheduled visit to the site. To further facilitate scheduling, cardiac evaluation by echocardiogram or MUGA during the study drug treatment and follow up phases may be performed up to 14 days before or after the scheduled visit to the site. Any assessment may be performed more frequently if clinically indicated.

To ensure a timely assessment of safety in patients who prematurely discontinue study drug or complete the 12-month study drug treatment phase, the Early Study Withdrawal Visit/Month 12 Visit should occur on or as soon as possible after early discontinuation or completion of study drug day.


Women must have no clinical or radiographic evidence of disease at the time of study entry. The specific details for timing of all clinical outcome assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, efficacy assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Efficacy assessments during the follow up phase may be performed up to 7 days before and up to 7 days after the scheduled visit to the site. To further facilitate scheduling, mammography during the study drug treatment and follow up phases may be performed up to 14 days before or after the scheduled annual test. Any assessment may be performed more frequently if clinically indicated.

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To ensure a timely assessment of efficacy in patients who prematurely discontinue study drug or complete the 12-month study drug treatment phase, the Early Study Withdrawal Visit/Month 12 Visit should occur on or as soon as possible after early discontinuation or completion of study drug day.

9.2.2. Subject Withdrawal from Study Drug

When applicable, all subjects who withdraw from study drug must continue to be followed for the study assessments and procedures, including follow-up procedures, as defined in Section 6 and at the time points indicated in the Time & Events Table in Section 14.1, Appendix 1. To ensure timely safety and efficacy assessments in patients who prematurely withdraw from study drug or complete the 12-month treatment period of study drug, the Early Study Withdrawal Visit/Month 12 Visit should occur on or as soon as possible after early discontinuation or completion of study drug day. Subjects who have disease recurrence may be asked to participate in additional research on biomarkers derived from a tumor tissue biopsy; participation is optional and refusal to participate will not lead to withdrawal from the clinical study.

Reason for change: Visit window increased for safety and efficacy assessments during the follow up phase of the study. Additional text was added to clarify the timing of the Early Study Withdrawal/Month 12 Visit.

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Amendment 6 Changes

The global Protocol Amendment No. 05 date, 21 May 2008, is replaced by Protocol Amendment No. 06, 25 January 2010. This amendment applies to all global participating investigative sites.

The following protocol change (item #1 below) has been implemented following feedback from the investigative sites and the request to increase the interval of the visit window in the follow up phase of the study. Given the importance of the objectives of the study, including determination of the effect of lapatinib on long-term disease-free and overall survival times in an adjuvant breast cancer patient population, the window for assessment visits in the follow up phase was widened to better accommodate subject and site schedules and to promote subject retention and ensure collection of long-term safety and efficacy data.

Additionally, new standard language is present on the Investigator Agreement Page which further defines the obligations of the Investigator for the study.


1. Sections 6.3.1. Clinical Outcome Assessment and 6.4 Health Outcomes


Women must have no clinical or radiographic evidence of disease at the time of study entry. The specific details for timing of all clinical outcome assessments are provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, efficacy assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Efficacy assessments during the follow up phase may be performed up to 7 21 days before and up to 7 21 days after the scheduled visit to the site. To further facilitate scheduling, mammography during the study drug treatment phase may be performed up to 14 days before or after the scheduled annual test and during the follow up phases may be performed up to 14 21 days before or after the scheduled annual test. Any assessment may be performed more frequently if clinically indicated.

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6.4. Health Outcomes

The SF-36 will be completed at baseline (prior to administration of first dose of study drug) and prior to any other study procedures, including physician interaction. During the study treatment period, the SF-36v2 will be completed every 6 months (i.e., at Month 6 and Month 12). After withdrawal from study drug, the SF-36v2 will be completed every 6 months for 24 months. The timing of health-related QoL assessment is provided in the Time & Events Table in Section 14.1, Appendix 1. To allow flexibility for scheduling, health-related QoL assessments during the study drug treatment phase may be performed up to 7 days before the scheduled visit to the site. Health-related QoL assessments during the follow up phase may be performed up to 21 days before and up to 21 days after the scheduled assessment.

2. Investigator Agreement Page

INVESTIGATOR AGREEMENT PAGE

For protocol number 06

I confirm agreement to conduct the study in compliance with the protocol, as amended by this protocol amendment.

I acknowledge that I am responsible for overall study conduct. I agree to personally conduct or supervise the described clinical study.

I agree to ensure that all associates, colleagues and employees assisting in the conduct of the study are informed about their obligations. Mechanisms are in place to ensure that site staff receives the appropriate information throughout the study.

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UM2005/00179/07 CONFIDENTIALEGF105485

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Amendment 7 Changes

The global Protocol Amendment No. 06 date, 25 January 2010, is replaced by Protocol Amendment No. 07, 08 February 2011. This amendment applies to all global participating investigative sites.

Investigative sites notified the study team that content was missing from Appendix 3 and 6. Therefore, in order to ensure that the protocol for EGF105485 is complete and thesites have all the tools to properly implement and conduct the trial, the protocol was amended to correct this error which occurred during the finalization of Protocol Amendment No. 06.

Additionally, the Sponsor contact information was updated.


SPONSOR INFORMATION PAGE

. . .

GlaxoSmithKline Greenford Road Greenford, Middlesex, UB6 0HE, UK Telephone: 1-3 Iron Bridge Road Stockley Park West Uxbridge, Middlesex, UB11 1BT Telephone Number:

. . .

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Division: Worldwide Development Retention Category: GRS019 Information Type: Pharmacogenetics Reporting and Analysis Plan

Title: Pharmacogenetics reporting and analysis plan for the determination of associations and predictive values of four MHC markers for lapatinib-associated ALT elevation and hepatotoxicity using patients with erbB2 over-expressing early stage breast cancer from EGF105485 (TEACH).


Effective Date: 26-JUL-2010

Description:

Previous studies using data from 13 advanced/metastatic breast cancer trials have identified and confirmed four genetic variants in a Class II MHC locus that are associated with lapatinib-induced ALT elevation. This document prospectively defines the analysis strategy for the reporting of the pharmacogenetic data from EGF105485 (TEACH). The TEACH study (Tykerb Evaluation After Chemotherapy) is a large randomised, placebo controlled study of lapatinib treated patients with early stage, erbB2 over expressing breast cancer. The primary analysis will: 1) determine estimates of the four previously confirmed MHC markers (three HLA alleles and one single nucleotide polymorphism (SNP) in TNXB) for associations with elevated isolated ALT and concurrent ALT/TBL in this patient population, and 2) determine the predictive value of these genetic markers in clinical management of liver safety in lapatinib treated patients. Additional exploratory analyses will be conducted to further our knowledge about any genetic contribution to hepatobiliary adverse events in the lapatinib-treated patients. Although at this time all patients have received one year of study treatment, EGF105485 is still an ongoing, treatment blinded study. This analysis will be conducted by a third party analyst, and individual patient-level treatment details will remain blinded to GSK staff and TEACH Correlative Science Committee members.

Subject: lapatinib, DILI, hepatotoxicity, ALT, HLA, MHC, pharmacogenetics, TEACH

Author’s Name(s), Title and Affiliation:

Statistical Genetic Analyst, GSK

Genetic Therapeutic Head for Oncology, GSK


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Approved by:

Approved by email 26 July 2010

SVP Genetics GlaxoSmithKline


Date

TEACH Medical Monitor GlaxoSmithKline


Date

TEACH Lead Project Statistician GlaxoSmithKline

Date

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TABLE OF CONTENTS

PAGE

1. INTRODUCTION ....................................................................................................... 6

2. GENETIC ASSOCIATIONS WITH DRUG INDUCED LIVER INJURY FROM PREVIOUS PHARMACOGENETIC STUDIES .......................................................... 7 2.1. Pharmacogenetics of Drug Induced Liver Injury ............................................ 7 2.2. Previous Lapatinib Drug Induced Associations with increased ALT .............. 7

3. STUDY DESIGN ........................................................................................................ 8

4. STUDY OBJECTIVES AND ENDPOINTS ................................................................. 9 4.1. Study Objectives ............................................................................................ 9 4.2. Study Endpoints ............................................................................................. 9

4.2.1. Strictly Defined ALT Cases and Controls ........................................ 9 4.2.2. Broadly Defined ALT Cases and Controls .................................... 10 4.2.3. Concurrent ALT/TBL Cases, Controls, and Non-Cases ............... 10

4.3. Hypotheses .................................................................................................. 10

5. DATA TRANSFER ................................................................................................... 10 5.1. Clinical Data (Not Including Treatment Assignment) .................................... 10 5.2. Treatment Assignment Information .............................................................. 12 5.3. Genetic Data ................................................................................................ 12

6. SAMPLE SIZE CONSIDERATIONS ........................................................................ 12 6.1. Power Calculations....................................................................................... 13

6.1.1. Power for ALT Case-Control Study in Lapatinib Arm .................... 13 6.1.2. Power for ALT/TBL Case-Control Study in Lapatinib Arm ............ 14

7. GENERAL CONSIDERATIONS FOR DATA ANALYSES ....................................... 15 7.1. Dependent Variables (Endpoint Variables) .................................................. 15 7.2. Independent Variables ................................................................................. 15 7.3. Genetic Markers ........................................................................................... 16 7.4. Marker Map .................................................................................................. 16 7.5. Examination of Ethnic Subgroups & Genetic Ancestry Estimates ................ 16 7.6. Multiple Comparisons and Multiplicity .......................................................... 16

8. DATA HANDLING CONVENTIONS......................................................................... 17 8.1. Premature Withdrawal and Missing Data ..................................................... 17 8.2. Derived and Transformed Data .................................................................... 17

9. STUDY POPULATION ............................................................................................. 17 9.1. Demographic and Baseline Characteristics ................................................. 17

10. PHARMACOGENETIC ANALYSES ........................................................................ 17 10.1. Data Quality Control ..................................................................................... 17

10.1.1. Genotype Quality Control .............................................................. 17 10.1.2. Subject Quality Control ................................................................. 18

10.2. Linkage Disequilibrium Analysis ................................................................... 18 10.3. Ancestry Estimation...................................................................................... 18

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10.4. Association Analyses ................................................................................... 19 10.4.1. Differences Between Lapatinib and Placebo Treatment

Arms .............................................................................................. 19 10.4.2. Strict Case-Control Analyses ........................................................ 19 10.4.3. Conditional Analyses for Restricted Case-Control Study .............. 20 10.4.4. ALT-Cases and Time-of-onset ...................................................... 20 10.4.5. Quantifying Clinical Utility ............................................................. 20 10.4.6. Longitudinal Analyses ................................................................... 20

10.4.6.1. Longitudinal Analyses for Entire Time-Course ............ 21 10.4.6.2. Longitudinal Analyses After Exceeding ALT

3xULN ......................................................................... 21

11. INTERPRETATION OF ASSOCIATION ANALYSES AND REPORTING OF RESULTS ................................................................................................................ 22 11.1. Assessment of Clinical Utility ....................................................................... 23

12. RESULTS SHARING WITH GSK AND TEACH CSC PRIOR TO STUDY UNBLINDING ........................................................................................................... 23

13. REFERENCES ........................................................................................................ 24

14. AGREED FORMATS FOR SHARING RESULTS .................................................... 26

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Trademark Information



Tykerb/Tyverb Herceptin SAS Xeloda

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1. INTRODUCTION

GlaxoSmithKline (GSK) is developing TYKERB/TYVERB™ (lapatinib, GW572016), a small molecule ErbB1/ErbB2 tyrosine kinase inhibitor (TKI), for the treatment of a variety of cancers, including breast cancer. Lapatinib was approved by the Food and Drug Administration (FDA) in the US on March 13, 2007 in combination with capecitabine (Xeloda) for the treatment of patients with advanced or metastatic breast cancer (MBC) whose tumors overexpress HER2 and who have received prior therapy including an anthracycline, a taxane, and trastuzumab (Herceptin). More recently (January 2010), lapatinib was approved in combination with letrozole for treatment of postmenopausal women with hormone positive metastatic breast cancer that overexpress HER2 receptor for whom hormonal therapy is indicated [TYKERB Package Insert, 2010].

With consideration of the FDA guidance document on distinguishing signals of drug induced liver injury (DILI) (http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM174090.pdf), GSK has been conducting retrospective analyses of the laboratory and clinical data from studies of lapatinib monotherapy and lapatinib in combination with other anti-cancer agents in patients with various stages of breast cancer.

The overall estimated incidence of possible Hy’s law cases (AST/ALT above 3xULN, TBL above 2xULN and ALP below 2xULN) on the GSK clinical program is 0.2%, or 0.1% based on cases with a possible association to lapatinib. Other TKIs have been associated with hepatobiliary events; however the mechanism is currently unknown. Possible mechanisms for lapatinib associated hepatobiliary events include enterohepatic recycling, inhibition of the biliary transporters SLCO1B1 (OATP1B1), ABCB1 (p-glycoprotein) and ABCG2 (BCRP) and a possible unspecified effect on the major bile acid export pumps ABCB11 (BSEP) and ABCB4 (MDR3). It is also possible that EGFR inhibition may impair liver regeneration. It has been reported that genetic variation may be an important factor in predicting susceptibility to drug induced hepatobiliary events [Navarro, 2006]. In addition, specific Human Leukocytic Antigen (HLA) polymorphisms within the Major Histocompatibility Complex (MHC) are strongly associated with hepatotoxicity for a small number of unrelated drugs and findings associating similar changes with ALT elevation have been identified for lapatinib (see Section 2.1 and Section 2.2).

This prospectively defined pharmacogenetic (PGx) study will be undertaken to determine the association of the previously confirmed MHC markers with signals of hepatotoxicity among patients treated with lapatinib in patients from EGF105485 (TEACH), and to determine the predictive characteristics of these associations for the clinical management of liver safety in this study population of patients with erbB2 over-expressing early stage breast cancer. All available patients with consented DNA samples from EGF105485 will be included in the present PGx evaluation. Since EGF105485 is an ongoing, treatment blinded study, this analysis will be conducted by a third party analyst, with individual patient-level treatment details remaining blinded to GSK staff and TEACH Correlative Science Committee members.

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This document describes the analyses planned to explore the impact of four MHC markers on lapatinib-induced elevations of isolated ALT and concurrent ALT/TBL elevations using case-control (CC) analyses. In addition, comparisons with the placebo control arm will allow evaluation of the contribution of the specified genetic associations with background levels of liver safety signals. A brief summary of the study design is provided, followed by descriptions of the analysis populations, analysis variables, and statistical methods that will comprise the analysis. As part of the assessment of the statistical association of genetic markers with relevant safety endpoints, the possible role of demographics, baseline characteristics, and covariates potentially associated with endpoint variables will be assessed.

2. GENETIC ASSOCIATIONS WITH DRUG INDUCED LIVER INJURY FROM PREVIOUS PHARMACOGENETIC STUDIES

2.1. Pharmacogenetics of Drug Induced Liver Injury

Specific Human Leukocytic Antigen (HLA) polymorphisms within the Major Histocompatibility Complex (MHC) are strongly associated with hepatotoxicity for unrelated drugs, including amoxicillin-clavulanate (HLA-DRB1*1501) [O'Donohue, 2000], anti-tuberculosis chemotherapy (HLA-DQB1*0201) [Sharma, 2002], ticlopidine (HLA-A*3303) [Hirata, 2008], ximelagatran (HLA-DRB1*0701) [Kindmark, 2007], flucloxacillin (HLA-B*5701) [Daly, 2009] and lumiracoxib (HLA-DRB1*1501) [Wright, 2009].

2.2. Previous Lapatinib Drug Induced Associations with increased ALT

A previous study was undertaken to screen for pharmacogenetic markers in the GSK DILI panel, candidate genes, or Illumina 1M Duo panel that are associated with observed elevations of on-treatment ALT in patients treated with lapatinib in the clinical studies EGF10023, EGF103892, EGF20009, EGF103009, EGF102580, EGF100151, EGF30001, EGF104900, EGF105764, EGF104383, EGF105084, and VEG20007 [GlaxoSmithKline Document Number RH2008/00066/01]. All patients were treated with lapatinib monotherapy or lapatinib in combination with another drug(s), including capecitabine, paclitaxel and trastuzumab. The results of this screening study suggested 58 variants as possibly associated with elevations in ALT case-control status. This study was followed with an independent confirmatory study (EGF30008, lapatinib plus letrozole versus letrozole in advanced/metastatic breast cancer) [GlaxoSmithKline Document Number RH2009/00008/00], which found four MHC variants associated with elevated ALT case-control status. The four variants are correlated and reside in the MHC Class II locus, consistent with a single association signal. This was supported by a conditional regression analysis, where after adjustment for either DQA1*0201 or DRB1*0701, the three remaining variants became non-significant (p>0.05) and DQA1*0201 showed the strongest association signal. These four variants are the focus of this study: HLA-DQA1*0201, HLA-DRB1*0701, HLA-DQB1*0202, and TNXB (rs12153855).

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3. STUDY DESIGN

EGF105485 is a phase III, randomized, double-blind, multicenter, placebo-controlled study of adjuvant lapatinib in women with early-stage ErbB2 overexpressing breast cancer. Eligible women must have completed primary neoadjuvant or adjuvant chemotherapy and must have no clinical or radiographic evidence of disease at the time of study entry. The primary objective of the clinical study is to determine whether adjuvant therapy with lapatinib will improve disease free survival. Secondary objectives include overall survival, recurrence-free survival, distant recurrence-free survival, CNS recurrence-free survival, and quality of life measures. Relevant to this PGx study, secondary safety objectives include determining the qualitative and quantitative toxicities associated with oral lapatinib administered daily versus placebo.

EGF105485 is an on-going study, and as of February 10, 2010, 3161 patients have been randomized to the two treatment arms (defined as the randomized population), of which 3147 have received at least one dose of study drug (defined as the intention-to-treat, ITT / Safety population). Among these patients, 2441 (78% of ITT population) had PGx consent and adequate DNA for genotyping as of November 9, 2009. These 2441 patients are the focus of this PGx study.

Table 1 EGF105485 Summary Patient Status for Pharmacogenetics

Patient Status (as of 25 May 2010) # Patients % Patients Missing Consent Information 2 0.1% Outstanding consent issues 10 0.3% Inadequate PGx consent 11 0.4% Not available at genotyping cut-off, now available 13 0.4% Duplicate Sample Issues 21 0.7% DNA Issues (low yield or concentration) 38 1.2% Consented, Sample not available 92 2.9% No Consent 519 16.5% Genotyped 2441 77.6% Total 3147 100.0% Note: These subject counts are accurate as of May 25, 2010. Some subjects have outstanding consent issues. These and additional subjects may be available for pharmacogenetic analyses in the future.

Relevant for genetic analyses, 44% of the ITT patients were recruited in Europe, 28% in Asia Pacific, 16% in North America, and 12% in Latin America. The breakdown of geographic ancestry is 72% Caucasian, 21% Asian, 5% other (American Indian/ Alaskan or Hawaiian Native /other Pacific Islander), and 4% African American (note that subjects may be reported in more than one geographic category).

As of February, 2010, 2402 (76%) patients have completed 12 months of treatment, and 744 (24%) discontinued treatment prematurely.

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4. STUDY OBJECTIVES AND ENDPOINTS

4.1. Study Objectives

The primary objectives of this study are to determine if four pre-specified MHC markers (HLA-DQA1*0201, HLA-DRB1*0701, HLA-DQB1*0202, and TNXB (rs12153855)) are associated with elevated isolated ALT and concurrent ALT/TBL in this patient population, and to determine the predictive value of these genetic markers in management of patient safety in this early stage breast cancer treatment population. These associations have potential to support mechanistic understanding and provide determination of clinical utility in terms of patient risk management through prediction of patients at increased risk of isolated ALT and concurrent ALT/TBL elevations when receiving lapatinib. To achieve these aims, we plan to perform a series of case-control analyses and longitudinal analyses of the quantitative measures related to liver chemistries.

4.2. Study Endpoints

Case-control analyses will be applied to assess lapatinib-induced elevations in isolated ALT and concurrent ALT/TBL to verify that the statistical associations previously observed hold in this new patient population that received a single type of treatment (lapatinib monotherapy) in early stage breast cancer, in contrast to the heterogeneous types of treatments (lapatinib monotherapy and in combination with other therapies) in advanced/metastatic breast cancer among patients in our prior studies. The present analysis will use the same case-control definitions as used in previous studies, to maximize comparability. These strict case-control definitions constrain baseline values to be within the normal ranges (≤1 x ULN), while per protocol, patients with ALT ≤3xULN at screening may have been allowed to enter the study. There are some patients that are neither strict cases nor controls by this definition, so in addition, broader definitions of cases and controls will be used in order to evaluate measures of clinical utility of the MHC genotypes amongst the entire available sample of lapatinib-treated patients.

Note that the definitions of cases and controls could be influenced by the frequency of LFT measurements, or the time on treatment. To address these concerns, we plan to compare the number of liver chemistry measures and time on treatment between cases and controls.

4.2.1. Strictly Defined ALT Cases and Controls

Strict ALT cases will be defined as lapatinib treated patients who had a baseline ALT measurement within the upper limit of normal range (≤1 x ULN) and one or more on-treatment ALT measurement >3 x ULN during the course of treatment. Exploratory analyses will evaluate more extreme elevations, such as >5x, and >10x ULN, and may be limited to descriptive analyses, depending on the number of events (a descriptive analysis will be conducted for five events or less).

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Strict ALT controls will be patients exposed to lapatinib for at least thirteen weeks, who had baseline and all of their on-treatment ALT measurements within the normal range. Previous analyses of lapatinib breast cancer trials showed that by thirteen weeks, approximately 50% of the ALT cases had their first ALT elevation >3xULN.

4.2.2. Broadly Defined ALT Cases and Controls

For determination of measures of clinical utility, any patient in EGF105485 who had one or more on-treatment ALT measurement >3 x ULN during the course of treatment will be considered a broad case, and all non-cases will be treated as broad controls. Although we do not expect baseline ALT measurements much above ULN, we will verify this and potentially exclude patients from the broad case category with baseline elevations.

4.2.3. Concurrent ALT/TBL Cases, Controls, and Non-Cases

Concurrent ALT/TBL Cases will be defined as patients with:

1. AST and/or ALT>3xULN and Total Bilirubin ≥2xULN and ALP<2xULN

2. AST and/or ALT>3xULN and Total Bilirubin ≥2xULN

Other reasons to explain the combination of increased ALT and TBL (e.g., viral hepatitis A, B, or C; pre-existing or acute liver disease; or another drug capable of causing the observed injury), will be investigated in these individuals and noted if determined.

Concurrent ALT/TBL controls will be patients exposed to lapatinib for at least thirteen weeks, who had baseline and all of their on-treatment ALT and TBL measurements within the normal range.

For determination of measures of clinical utility, all patients who do not qualify as Concurrent ALT/TBL cases at a particular threshold, will be categorized as Concurrent ALT/TBL non-cases.

4.3. Hypotheses

The primary hypothesis is that lapatinib-induced elevations in isolated ALT and concurrent ALT/TBL in patients from EGF105485 are associated with one or more of the four pre-specified MHC markers. An additional hypothesis is that these associations will results in markers with predictive values which may translate into clinical utility.

5. DATA TRANSFER

5.1. Clinical Data (Not Including Treatment Assignment)

The specified EGF105485 clinical data will be transferred to in SAS datasets via the

TEACH_GENETICS_EGF105485 alliance portal. This is a secure web portal maintained by GSK. Access to this portal will be restricted to the TEACH Genetics and Statistics team as well as All datasets that are provided to

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will not contain true patient treatment assignment. One dataset containing study populations will contain dummy treatment codes. The treatment assignment details are in fact not available to the GSK TEACH statistics and genetics team hence could not be provided. A copy of the annotated eCRF will be provided to give details of the mapping of the variables within the datasets. Section 5.2 has details on providing the treatment assignment information. The following table provides a summary of the data that will be provided:

Table 2 Details of Clinical Datasets to be provided

Type of information Source Cleaned and Validated

Specific data points

Treatment assignment Random code to be obtained from GSK Independent Statistician (non-Oncology)

Yes Randomization number Assigned treatment

Treatment Information eCRF yes Treatment Start Date Treatment Stop Date Randomization Date

Demography / Race eCRF yes Date of birth Gender Weight Height Race Ethnicity

Prior Medical history/Prior and New Anti-Cancer medications/Concurrent medications

eCRF Yes Pre-existing conditions Current medical conditions Baseline Anti-Cancer medications Concurrent medications Start and stop dates for new medications

Disease Characteristics eCRF yes Date of Initial Diagnosis (ID) Stage at Initial Diagnosis Primary Tumour Type at ID TN Staging at ID Histology at ID Primary Tumour in Situ Date of Biopsy Estrogen Receptor Status Progesterone Receptor Status ErbB2 Status ImmunoHisto Chemistry (IHC) Fluorescence in Situ Hybridization (FISH) (eCRF and Quest)

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Type of information Source Cleaned and Validated

Specific data points

Tumor Genetics yes Consent Hepatobiliary Lab Data1 QUEST and

eCRF yes AST

ALP ALT Bilirubin Possible Hy’s Law subjects2

1. Hepatobiliary labs data was originally collected at screening, every three months while on one-year of treatment, and at study withdrawal/closure. Protocol amendments made in May of 2008 increased the frequency of on-treatment measures from every three months to every six weeks.

2. Aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) > 3x upper limit of normal (ULN) and Total bilirubin ≥2x ULN and alkaline phosphatase (ALP) < 2x ULN

5.2. Treatment Assignment Information

Because EGF105485 is an ongoing study, these planned PGx analyses will be conducted by a third party ( at while the TEACH Correlative Science Committee and GlaxoSmithKline will not have access to data with treatment assignment of individual patients, until the study is unblinded. For this reason, all reported analyses will be summary information only, maintaining blinding of treatment arms.

The randomisation of patient treatment assignment will be provided to the third party after the RAP has been completed, agreed upon by all parties, and shared with regulators at the FDA for review. This information will be transferred directly to the external analyst, by the independent GSK statistician for EGF105485, The process for acquiring the unblinded treatment information will be in the formal request to the randomisation coordinator at GSK in accordance with SOP’s. Once the request has been approved the randomisation details will be released to who will send this information to within a maximum of 3 working days.

5.3. Genetic Data

The four pre-specified MHC genetic markers will be provided to the third party after the RAP has been completed, agreed upon by all parties, and shared with regulators at the FDA for review.

6. SAMPLE SIZE CONSIDERATIONS

In EGF105485, 78% of the safety population provided informed consent, a DNA sample and clinical data available for genotyping. However, EGF105485 was not prospectively designed to address specific PGx research hypotheses and, thus, did not benefit from prospective sample size calculations.

Limitations: The following power calculations are based on the total number of ITT patients who gave consent and have adequate DNA available for genotyping. These counts, and corresponding power, could be reduced by removing patients due to poor genotype quality in QC steps. Because we expect few exclusions, the following should be

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adequate approximations. Furthermore, the calculations do not account for inclusion of statistically significant covariates. If some covariates are poorly balanced across HLA genotypes, then power could be less than that given below.

6.1. Power Calculations

6.1.1. Power for ALT Case-Control Study in Lapatinib Arm

Basic power calculations are conducted to inform what kinds of genetic effects could be found with the expected sample sizes and the expected genetic associations reported in the prior confirmatory study. From the clinical data available as of June, 2010, for patients treated with either lapatinib or placebo, there are 2441 subjects from the TEACH treated population who had given PGx consent and had adequate DNA for genotyping. This number diminishes slightly when the restrictions that the ALT lab values must be recorded after the start of treatment and within 30 days of treatment. Within this group,33 patients met the strict ALT case definition (baseline ALT<=1xULN and max ALT>3xULN), and 2080 patients met the strict control definition (baseline and max ALT<=1xULN and treatment duration>=13 weeks).

Power calculations are derived for these strict case-control definitions, using theodds-ratios (ORs) found in the prior confirmatory study, as well the minimal detectable OR for specified power.

Scenario-1: If all 33 ALT-cases occur in the lapatinib arm, and 50% of the controls are in the lapatinib arm (2080*0.5=1040 patients)’

Scenarios-2: If 80% of the ALT-cases occur in the lapatinib arm, we would expect 26 cases and 1040 controls in the lapatinib arm.

With these two scenarios for numbers of cases and controls, we present the minimum detectable OR for 80% or 90% power, using one-sided Type-I error rates of 0.025 for each of the four MHC markers. The carrier frequencies were those reported in the confirmatory study among controls, and for contrast, we also presented the OR and 95% confidence intervals (CI) reported in the prior confirmatory study. The power in Table 3 illustrates that we have sufficient power to detect associations that have ORs much smaller than those reported in the confirmatory study.

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Table 3 Power for ALT Case-Control Study in Lapatinib Arm

HLA Marker and Risk Genotype

Carrier Frequency

Confirmatory Study OR (95% CI)

Minimum Detectable OR for 80% or 90% Power Scenario-1 Scenario-2 80% 90% 80% 90%

HLA-DQA1 *0201 carrier 0.21 9.0 (3.2-27.4) 2.9 3.4 3.3 3.8 (heterozygous or homozygous)

TNXB rs12153855 0.19 7.2 (2.6-20.5) 3.0 3.5 3.4 4.0 (CC/CT genotype)

HLA-DQB1 *0202 carrier 0.19 6.9 (2.5-19.6) 3.0 3.5 3.4 4.0 (heterozygous or homozygous)

HLA-DRB1 *0701 carrier 0.23 6.9 (2.5-19.9) 2.9 3.3 3.2 3.7 (heterozygous or homozygous)

6.1.2. Power for ALT/TBL Case-Control Study in Lapatinib Arm

From clinical data available as of June, 2010, seven patients with PGx consent and adequate DNA for genotyping experienced an AST and/or ALT > 3xULN and TBL > 2xULN and ALP < 2xULN. Furthermore, there are 1770 concurrent ALT/TBL controls (baseline & max ALT and total bilirubin <=1xULN & treatment duration>=13 weeks).

Scenario-1: If all 7 ALT/TBL-cases occur in the lapatinib arm, and 50% of the controls are in the lapatinib arm (1770 * 0.5 = 885 controls)..

Scenarios-2: If 80% of the ALT/TBL-cases occur in the lapatinib arm, we would expect 5 cases and 885 controls in the lapatinib arm.

With these two scenarios for numbers of cases and controls, we present the minimum detectable OR for 80% or 90% power, using one-sided Type-I error rates of 0.025 for each of the four HLA markers. The carrier frequencies were those reported in the confirmatory study among controls. The power in Table 4 illustrates that we will only have sufficient power to detect very large ORs, at least 8. Nonetheless, this magnitude of OR would likely translate to useful clinical utility for these high-risk cases.

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Table 4 Power for ALT/TBL Case-Control Study in Lapatinib Arm

HLA Marker Carrier Frequency

Minimum Detectable OR for 80% or 90% Power

and Risk Genotype Scenario-1 Scenario-2 80% 90% 80% 90% HLA-DQA1 *0201 carrier (heterozygous or homozygous) 0.21 8.2 10.5 11.1 14.8 TNXB rs12153855 CC/CT genotype 0.19 8.5 10.7 11.5 15.1 HLA-DQB1 *0202 carrier (heterozygous or homozygous) 0.19 8.5 10.7 11.5 15.1 HLA-DRB1 *0701 carrier (heterozygous or homozygous) 0.23 7.9 10.3 10.8 14.7

7. GENERAL CONSIDERATIONS FOR DATA ANALYSES

It is anticipated that after an initial review of the results of the analyses described here, there may be a need for additional follow-up analyses to be conducted. These will be discussed, defined, and agreed by the authors of this RAP and other relevant parties at that time. This RAP will not be updated to include such a case; any additional follow-up analyses will be described in a pharmacogenetic study report.

7.1. Dependent Variables (Endpoint Variables)

Refer to Section 4.2 for specific definition of study endpoints to be analyzed.

7.2. Independent Variables

Association analyses of strict cases and controls will include baseline ALT measures and genetic ancestry estimates as covariates within the model, consistent with covariates adjusted for in the prior exploratory and confirmatory studies.

Additional variables may be assessed for their association with the endpoint variables and evaluated for their potential impact on the primary genetic association analyses, including:

• Baseline measures of TBL

• Age

• Race and Ethnicity

• Hormone receptor status

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• Additional clinical variables delivered as part of the clinical data transfer (see Table 2, Section 5.1)

7.3. Genetic Markers

Germline DNA will be extracted from peripheral blood. Classical HLA genotyping will be performed for HLA-DQA1, HLA-DQB1, and HLA-DRB1. Genotype data for TNXB rs12153855 will be generated using the Illumina 1M-Duo.

For analyses, binary carrier status (yes vs. no) will be defined for each of the following four risk genotypes:

1) HLA-DQA1 *0201 carrier (heterozygous or homozygous) 2) TNXB rs12153855 CC/CT genotype 3) HLA-DQB1 *0202 carrier (heterozygous or homozygous) 4) HLA-DRB1 *0701 carrier (heterozygous or homozygous)

In addition, to evaluate genotypes for specific alleles, such as 0201, we will code three genotypes, such as 0201/0201, 0201/X, and X/X, where X is all other alleles.

7.4. Marker Map

The most recent NCBI map will be used (currently NCBI 36).

7.5. Examination of Ethnic Subgroups & Genetic Ancestry Estimates

DQA1*0201 allele carriage differs according to race and ethnicity. Population reference data from the New Allele Frequency Database (http://www.allelefrequencies.net) shows that DQA1*0201 allele carriage is common in patients with Caucasian (25%), African American (20%), Hispanic (20%) and Asian (15%) ethnicities, but a lower carriage frequency is observed in Japanese populations (1%).

Genetic ancestry estimation will be conducted by the genetics group at GSK using all EGF105485 treatment-blinded patients available for pharmacogenetics and genotype data from the Illumina 1M Duo (See Section 10.3 for details). The resulting genetic ancestry estimates, but not the additional genotype data from which they were derived, will be provided to Genetic ancestry estimates will be used, along with self-reported race, ethnicity and country information, to define distinct clusters of genetically homogeneous subgroups of patients for further investigation. If feasible, exploratory evaluation of the Asian subgroup may be informative, as described in Section 10.4.

7.6. Multiple Comparisons and Multiplicity

We do not correct for multiple testing of the four markers for two reasons: 1) our specific hypotheses are based on the prior exploratory and confirmatory studies; 2) the HLA markers are very highly correlated, almost to the point of “effectively” one marker, and a single genetic signal of interest. Also, there is no need to correct for multiple case-

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control definitions, as only the strictly defined cases and controls will be used for significance testing.

8. DATA HANDLING CONVENTIONS

8.1. Premature Withdrawal and Missing Data

If a patient contributed data to the analysis population and also provided a DNA sample, then the patient will be included in the analyses outlined here. If a patient withdrew from the study but did not withdraw consent for pharmacogenetic research, the patient’s information may still be used in these analyses.

Missing data will not be imputed in the analysis.

8.2. Derived and Transformed Data

The distribution of any quantitative variables to be included in the analysis model will be assessed, and suitable transformations will be considered if deviations from normality are expected to influence the interpretation of statistical hypotheses being tested.

9. STUDY POPULATION

9.1. Demographic and Baseline Characteristics

The number of patients included in the analysis population will be summarized overall and may be summarized more specifically by relevant independent variables including demographic and clinical information, keeping treatment arm blinded.

10. PHARMACOGENETIC ANALYSES

Genotypes for the four MHC markers will be analyzed. The analysis strategies are outlined in this section.

10.1. Data Quality Control

10.1.1. Genotype Quality Control

For Illumina 1M-Duo genetic marker quality control, markers with valid genotypes for <95% of patients will be removed. Genotypes for twelve HapMap subjects typed as positive controls will then be compared with reference data provided by Illumina, and any markers with >1 discordant genotype will be removed.

With HLA genotyping, twelve HapMap subjects were typed as positive controls. HLA data for these HapMap subjects will be compared with data from Sanger and data generated for previous GSK studies. Data must be 100% concordant in order for study data to be progressed. The level of association between HLA-DQA1*0201 and HLA-DRB1*0701 and also between HLA-DQA1*0501 and HLA-DRB1*0301 will be reviewed as an additional check. These pairs of alleles should be found together in at least 95% of samples.

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10.1.2. Subject Quality Control

For Illumina 1M-Duo subject quality control, subjects with valid genotypes for <90% of markers will be removed.

All non-China-based samples will be typed internally on a subset of seventy-eight markers from the Illumina 1M-Duo using a modification of the single base chain extension assay described in Taylor, et al. Similarly, the China-based samples will be typed on ten markers from the 1M-Duo panel using the TaqMan platform. Concordance with the 1M-Duo data will be reviewed in each case to detect and remove any misidentified samples or samples with low quality data.

10.2. Linkage Disequilibrium Analysis

Linkage disequilibrium (LD) analysis will be conducted to measure the association between alleles at different loci. The LD between two alleles at two different markers is given by DAB = pAB – pApB, where pA is the allele frequency of A allele of the first marker, pB is the allele frequency of B allele of the second marker, and pAB is the joint frequency of alleles A and B on the same haplotype. A commonly used scaled measure of LD, r2, will be utilized in this study and is calculated as follows:

)ˆ~)(ˆ~(

ˆ

BBAA

AB

DD r

++

∆=

ππ where

22 ~~ˆ,~~ˆ,~1~~,~1~~BBBBAAAABBBAAA pPD pPD )p-(p )p-(p −=−=== ππ

BAABAB pp -nn

~~21ˆ =∆

Haplotype frequencies will be computed by the expectation-maximization algorithm. Pairwise LD in the form of r2 (the squared correlation of genotypes of a pairwise SNP combination) will be presented using tabular summaries. In addition, we will compare these measures of LD between the four MHC markers of interest within different major ethnic groupings.

10.3. Ancestry Estimation

Eigenvector analyses will be conducted on all EGF105485 patients using Illumina 1M Duo genotype data that passes quality control and 269 HapMap subjects with available reference data for the same platform. Previously identified regions that may negatively affect these analyses may be removed including: the LCT region (Chr2), MHC region (Chr6), and two known inversions (Chr8 and Chr17) [Nelson, 2008; Novembre, 2008]. Autosomal SNPs will be further filtered to avoid artefacts that may be the results of long-range linkage disequilibrium. This will be done using PLINK software [Purcell, 2007] to remove SNPs correlated (r2>0.50) under the default settings of a sliding window of 50 SNPs, shifted by 5 SNPs each time. Eigenvector analyses will be carried out using smartpca [Patterson, 2006] implemented through EIGENSOFT software with default

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parameters including: generation of the significant eigenvectors (p < 0.05), five outlier detection iterations, and six standard deviations for outlier detection.

For patients without valid Illumina 1M Duo data, but with other valid genotypes for analysis, top eigenvector values may be imputed for these patients, using the mean of eigenvectors from other patients from the same country and of the same self-reported ancestry, for use as covariates in the model for ancestry adjustment, as necessary.

Patients with conflicting ancestry will either be removed from analyses or classified according to their genetics informed classification, depending on how they cluster.

10.4. Association Analyses

10.4.1. Differences Between Lapatinib and Placebo Treatment Arms

We will evaluate whether there is a significant difference in the rates of liver signal elevations between the lapatinib and placebo arms by comparing event-rates per patients exposed in the two arms. We will also compare the duration of assessments among patients for the two treatment arms to be sure that any observed difference in the event rates are not likely to be caused by differences in duration of assessments. If the lapatinib-treated patients experience significantly more events than the placebo arm, and the placebo arm has at least 5 events, we will evaluate whether the difference in risk between the lapatinib and placebo arms varies according to MHC carrier status for each of the four MHC markers. Formal statistical testing of a test for treatment-MHC interaction on liver signal elevation will not have sufficient power, so we plan to present statistical summary information in terms of odds ratios and their 95% confidence intervals.

Patients enrolled in Study EGF105485 had standard chemistry laboratory assessments within 4 weeks of the first dose of study drug, every 3 months during treatment, and at the time of discontinuation of study drug. All laboratory assessments with significant abnormal values during participation in the study or within 30 days after the last dose of study drug should be repeated until the values returned to normal. This frequency of laboratory assessments was implemented from the start of the study in August 2006 up until the amendment of the protocol in May 2008. Protocol Amendment 05, approved in May 2008, increased the frequency of standard chemistry to every 6 weeks. It should be noted, more than half of the patients had discontinued study treatment when Protocol Amendment 05 was implemented.

10.4.2. Strict Case-Control Analyses

Case-control analyses will be conducted by comparing the distribution of HLA genotypes between cases and controls in the lapatinib-treated arm using contingency table analyses, as well as penalized likelihood logistic regression [Heinze, 2006] that will allow us to control for covariates, and estimate odds ratios and their confidence intervals. Baseline ALT measures and genetic ancestry estimates will be included as covariates, consistent with covariates adjusted for in the prior exploratory and confirmatory studies. Additional variables may be assessed for their association with the endpoint variables and evaluated for their potential impact on the association analyses (See Section 7.2). Based on the

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prior studies, we expect that carrier status of specific HLA alleles will capture their association with case status, although we will also evaluate the association of genotypes (e.g., homozygous carriers, heterozygous carriers, versus noncarriers of specific alleles).

10.4.3. Conditional Analyses for Restricted Case-Control Study

In the prior confirmatory study, the genomic proximity and correlation amongst the HLA polymorphisms was consistent with a single association signal. This was supported by a regression analysis that adjusted for either HLA-DQA1*02:01 or HLA-DRB1*07:01, with findings that the three remaining variants became non-significant (p>0.05). We plan similar types of analyses for the case-control study, recognizing that we still need to be cautious about interpretations because of the high degree of colinearity among the HLA markers.

10.4.4. ALT-Cases and Time-of-onset

For cases with ALT > 3xULN, we will describe their time-of-onset by summary statistics (mean, standard deviation, median) stratified on treatment arm and MHC carrier status. The cumulative incidence over time, conditional on having an event, will be plotted for these strata, and formal statistical analyses will be conducted by Wilcoxon rank sum tests for two-group comparisons, and nonparametric ANOVA when evaluating the contributions from treatment arm, MHC carrier status, and their interactions. If sufficient numbers of cases with higher thresholds of ALT elevations (ie. ALT>5x and >10x ULN) or concurrent ALT/TBL cases are available, similar analyses will be conducted for these groups also.

10.4.5. Quantifying Clinical Utility

The clinical utility of the HLA markers will be quantified by measuring sensitivity (Sn), specificity (Sp), positive-predictive value (PPV), and negative-predictive value (NPV) (See Section 11.1 for details). These measures will be presented along with their corresponding 95% confidence intervals for interpretation.

The above analyses will be repeated for cases defined with ALT > 5xULN and cases with ALT >10xULN, if there are at least 5 events in these defined case definitions. They will also be repeated for the concurrent ALT/TBL case-control analyses.

10.4.6. Longitudinal Analyses

To evaluate how HLA carrier status, treatment arm, and possibly other clinically relevant covariates, influence the time-course of ALT values, we plan to analyze quantitative levels of ALT while patients are on-treatment, and up to 30 days after last treatment. We recognize that that these types of longitudinal analyses require careful attention to correlated observations over time within patients, varying numbers of measurements, and timing of measurements, across patients, and concerns about whether missing values (or measurements beyond required per protocol) occur randomly. We also recognize that the trajectory of measured values for a patient might not be a smooth function over time, such as linear or quadratic, and that the fluctuations might be “spiky” for some patients, particularly for patients who have a high ALT value and go off treatment, so subsequent

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ALT values might rapidly decrease. Because of these concerns, we plan to use longitudinal analyses mainly for exploratory and descriptive purposes. Furthermore, we plan two main analyses: 1) longitudinal analyses for the entire time-course for all patients; 2) longitudinal analyses for the subset of patients that have an ALT 3xULN, to describe how their ALT trajectory evolves after the first elevation of ALT 3xULN. This latter analysis is aimed to describe how the ALT evolves after its initial peak, and whether the subsequent time course depends on HLA genotypes and time on-study (the time of the first elevated ALT 3xULN).

10.4.6.1. Longitudinal Analyses for Entire Time-Course

To evaluate how the time-course of ALT levels vary according to HLA status and treatment arm (and possibly other clinical covariates) during the entire time on-treatment, we will use hierarchical models that will allow us to evaluate the roles of HLA carrier status, randomized treatment arm, and time, while allowing different number of observations over patients, and different times of the measurements. To flexibly model how ALT varies over time, we will use restricted cubic splines for the longitudinal model, where follow-up time is used to create the basis functions for the cubic splines. We plan to begin analyses with cubic splines in order to allow the greatest flexibility modelling the time-course of ALT values, but hope that we could reduce the number of regression parameters to simpler models, such as linear or quadratic. Choice of models will be based on Bayes Information Criterion (BIC).

The hierarchical model will be composed of a structural model and a random effects model. The structural model includes a longitudinal model applied to each patient’s longitudinal data, and then “links” these patient-specific longitudinal parameters (e.g., intercept, slope, etc.) with covariates, such as treatment arm or HLA genotypes. These two structural models form a hierarchical model of an individual-level model (stage-1) and population-level models (stage-2). A random effects model is used to partition random departures from the structural models into components of between patient variability (e.g., how patient-specific longitudinal parameters differ from the population averages) and within patient variability (e.g., the patient variability not explained by their longitudinal model for time effects). The between patient variability evaluates how patient-specific parameters vary from the population means (fixed effects) by introducing patient-specific random effects. The within-patient variability subsumes random errors, measurement errors, and any errors resulting from model misspecification. The models will be fitted with SAS Proc MIXED.

These types of exploratory analyses will allow us to evaluate how the time-course of ALT levels vary according to HLA status and treatment arm during the entire time on-treatment.

10.4.6.2. Longitudinal Analyses After Exceeding ALT 3xULN

To model whether ALT resolves (reduces to within normal limits), and whether this depends on HLA genotypes or the time on-treatment, we will perform longitudinal analyses similar to those described above, but with the following changes. First, we will subset to only those patients that have an ALT > 3xULN. Second, we will “restart the clock” for these patients, so that the first time (time-0) is the first time at which ALT >

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3xULN. This means that even though different patients have different times-on-treatment at which their first ALT > 3xULN occurs, the time of the first elevation will be set to 0 for all patients. Subsequent times will be measured relative to this initial time. But, we will use the actual time at first elevation as a covariate in our analyses. In this way, we will be able to model the ALT time trajectories after an initial rise, to determine if the subsequent time-course of ALT depends on HLA genotypes, or depends on time at which the initial rise occurred (e.g., whether resolution is more rapid for patients with little treatment vs. those with more treatment).

We will also determine the time to resolution (ALT ≤1x ULN) for all patients that experience ALT >3x ULN and whether this depends on HLA genotypes, the time on-treatment and possibly other clinical covariates.

Further, we will conduct a descriptive analysis of the number of patients who fall into the following categories following first ALT >3x ULN elevation and whether this depends on HLA genotypes, the time on-treatment and possibly other clinical covariates.

1) ‘Resolved’ (ALT ≤1x ULN)

2) ‘Decreased’ (1x ULN < ALT ≤ 3x ULN)

3) ‘Maintained’ (ALT >3x ULN)

4) No data available after first ALT >3x ULN

We recognize the potential problems from informative missing data, or from some patients having a larger number of measures because of concerns about their liver function. To evaluate this potential problem, we will categorize patients into 3 categories according to the timing and number of ALT measurements: 1) those that have measurements per protocol, 2) those that have fewer than protocol, 3) those that have more than protocol. We will then use this 3-level categorical variable as a covariate in the longitudinal analyses, to determine whether it has a significant impact on the models. If so, then this “pattern” analysis would suggest that interpretations of the longitudinal analyses should be cautious because of potential biases from informative missing data.

11. INTERPRETATION OF ASSOCIATION ANALYSES AND REPORTING OF RESULTS

The issues and questions we plan to address, and ultimately report, are the following.

Do the ALT Case-Control findings from the four previously confirmed MHC markers hold in this patient population? Since the patients in this EGF105485 study have completed monotherapy treatment for early stage breast cancer and were disease free at study entry, they contrast to patients in the prior studies who were treated with a variety of different types of treatments for advanced/metastatic breast cancer. Therefore we expect that the associations in this planned study might be stronger. This study also allows provides a cleaner evaluation of the predictive value and potential clinical utility of the HLA markers.

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Do the longitudinal analyses provide insights to the role of HLA genotypes on the rate of change of liver chemistry measures during the course of lapatinib treatment, and do the HLA genotypes influence the resolution of elevated ALT to within normal limits?

Are the results consistent across multiple subgroups (defined by clinical or demographic data)?

Do data suggest clinical options for management of DILI safety risk in lapatinib treated adjuvant breast cancer patients?

11.1. Assessment of Clinical Utility

Clinical utility will be evaluated with the broadly defined cases and controls, after verifying the risk of the genetic marker(s) within the strict definition of cases and controls. Measures of clinical utility will be calculated according to the following parameters:

Odds Ratio: The odds of cases having the suspect genotype to the odds of controls having the suspect genotype.

Sensitivity: The probability that a case will have the risk genotype.

Specificity: The probability that a control will not have the risk genotype.

Positive Predictive Value: The probability that a person will be a case, given that they have the risk genotype.

Negative Predictive Value: The probability that a person will be a control, given that they do not have the risk genotype.

12. RESULTS SHARING WITH GSK AND TEACH CSC PRIOR TO STUDY UNBLINDING

All analyses shared with GSK and the TEACH Correlative Science Committee will be summarized by treatment arm. These unblinded reports will include comparisons where the two arms are labeled with treatment assignment (i.e., Treatment A or Treatment B). All persons involved in this analysis in both GSK and the TEACH Correlative Science Committee will be supplied the decodes relating to Treatment A and Treatment B (i.e., lapatinib 1500mg or placebo) by the external analyst, Only summarized tables and figures will be shared, as detailed in Section 14. No individual patient-level data will be shared with GSK and the TEACH CSC. Furthermore, the external analyst or anyone at the will not have access to any efficacy data at any stage; only safety and baseline information will be provided.

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13. REFERENCES

Daly A, Donaldson PT, Bhatnagar P, et al, HLA-B*5701 genotype is a major determinant of drug-induced liver injury due to flucloxacillin. Nature Genetics 2009; 41: 816-819.

GlaxoSmithKline Document Number RH2008/00066/01 Pharmacogenetics Reporting and Analysis Plan for the Investigation of Associations between Genetic Markers and Elevated Alanine Aminotransferase Levels and/or Total Bilirubin Concentration in subjects treated with TYKERB™ Mono- and Combination-Therapy in studies EGF10023, EGF103892, EGF20009, EGF103009, EGF102580, EGF100151, EGF30001, EGF104900, EGF105764, EGF104383, EGF105084, and VEG20007. Effective Date: 12-FEB-2009

GlaxoSmithKline Document Number RH2009/00008/00 Pharmacogenetics Reporting and Analysis Plan for the Investigation of Associations between Genetic Markers and Elevated Alanine Aminotransferase Levels and/or Total Bilirubin Concentration in subjects treated with Tykerb and Letrozole in clinical trial EGF30008. Effective Date: 26-JUN-2009

Guidance for Industry, Drug-Induced Liver Injury: Premarketing Clinical Evaluation available at http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM174090.pdf; accessed 01 April 2010.

Heinze, G. 2006. "A comparative investigation of methods for logistic regression with separated or nearly separated data". Statistics in Medicine 25:4216-4226

Hirata K, Takagi H, Yumamoto M et al. Ticlopidine induced hepatotoxicity is associated with specific Human Leukocytic Antigen genomic subtypes in Japanese patients: a preliminary case control study. The Pharmacogenomics Journal, 2008; 8: 29-33.

Kindmark, A, Jawaid A, Harbron CG et al. Genome-wide pharmacogenetic investigation of a hepatic adverse event without clinical signs of immunopathology suggests an underlying immune pathogenesis. Pharmacogenomics Journal, 2007; 1-10.

Navarro V.J., Senior, J.R. 2006. “Drug-related hepatotoxicity.” New Engl J Med. 354 (7):731-9.

Nelson, MR, et al. (2008) “The Population Reference Sample, POPRES: A Resource for Population, Disease, and Pharmacological Genetics Research”. The American Journal of Human Genetics 83, 347–358.

Novembre, J, et al. (2008) “Genes mirror geography within Europe”. Nature. Vol 456:6, 98-101.

O'Donohue, J. et al. 2000. "Co-amoxiclav jaundice: clinical and histological features and HLA class II association". Gut 47:717-720.

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Patterson, N, et al. 2006. "Population Structure and Eigenanalysis". PLoS Genetics Vol 2, Issue 12, e190: 2074-2093.

Purcell S, et al. (2007) “PLINK: a toolset for whole-genome association and population-based linkage analysis.” American Journal of Human Genetics, 81:559-575.

Sharma, S.K. et al. 2002. "Evaluation of Clinical and Immunogenetic Risk Factors for the Development of Hepatotoxicity during Antituberculosis Treatment". Am J Respir Crit Care Med 166:916-919.

Taylor, JD, Briley D, Nguyen Q, et al, Flow cytometric platform for high-throughput single nucleotide polymorphism analysis. Biotechniques 2001; 30, 661–669.

TYKERB (lapatinib) Product Information. 2010.

Wright TM. MHC II Haplotype marker for lumiracoxib injury. Presented at 9th Annual FDA/PhRMA/AASLD Hepatotoxicity Meeting, March 2009.

Software

EIGENSOFT version 2.0 BETA software package.

PLINK (version number). Author: URL: http://pngu.mgh.harvard.edu/purcell/plink/

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14. AGREED FORMATS FOR SHARING RESULTS

Flow diagram of study design (patients, cases and controls, markers tested, significant results)

Patient summary tables: # of PGx patients available in each arm, demographics (ITT vs. PGx vs. Cases/Controls), ancestry groups (defined by smartPCA), Summary of liver chemistry measures, Summary of # of cases and controls by treatment arm, Summaries around time-to-onset of ALT>3xULN

Table of LD between markers (all and by ancestry groups)

Table of liver chemistry elevations in placebo vs. treated patients

Table of Results from lapatinib treated patients strict case-control analysis: p-values for each marker from same model as used in previous analyses [Penalized logistic regression (Firth option in SAS), Strict cases and controls, Model: CC = Baseline ALT + Ancestry Estimates + Genetic Marker]

Table of Conditional analysis Results: P-values for remaining markers after conditioning on each, one at a time, using the replication model (above)

Cumulative incidence plots of ALT (grouped by treatment and genotypes)

Table of Measures of clinical utility in the lapatinib-treated arm using broadly defined cases and controls

Tables of Results from longitudinal analyses: Exploratory models on entire time-course and time after first ALT>3xULN, Summary of how patients’ ALT values progress after first ALT>3xULN

Table of Types of liver injury (hepatocellular, mixed, cholestatic) observed in cases and genotype frequencies within each group

Similar tables/figures for more severe ALT thresholds (ie. ALT>5x and 10x ULN) where appropriate

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