Composition comprising aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan (FOLFIRI)

Abstract

Pharmaceutical composition comprising aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinocetan (FOLFIRI) useful in the treatment of Colorectal cancer (CRC).

Claims

1. A method of treating colorectal cancer (CRC) or colorectal cancer (CRC) symptom in a patient in need thereof, said method comprising administering to said patient therapeutically effective amounts of aflibercept, leucovorin, 5-fluorouracil (5-FU) and irinotecan, wherein the leucovorin is administered at a dosage comprised between about 200 mg/m.sup.2 and about 600 mg/m.sup.2, the 5-fluorouracil (5-FU) is administered at a dosage comprised between about 2000 mg/m.sup.2 and about 4000 mg/m.sup.2, the irinotecan is administered at a dosage comprised between about 100 mg/m.sup.2 and about 300 mg/m.sup.2 and the aflibercept is administered at a dosage comprised between about 1 mg/kg and about 10 mg/kg.

2. A method of increasing overall survival (OS) in a patient afflicted with CRC, said method comprising administering to said patient therapeutically effective amounts of aflibercept, leucovorin, 5-fluorouracil (5-FU) and irinotecan, wherein the leucovorin is administered at a dosage comprised between about 200 mg/m.sup.2 and about 600 mg/m.sup.2, the 5-fluorouracil (5-FU) is administered at a dosage comprised between about 2000 mg/m.sup.2 and about 4000 mg/m.sup.2, the irinotecan is administered at a dosage comprised between about 100 mg/m.sup.2 and about 300 mg/m.sup.2 and the aflibercept is administered at a dosage comprised between about 1 mg/kg and about 10 mg/kg.

3. A method of increasing progression free survival (PFS) in a patient afflicted with CRC, said method comprising administering to said patient therapeutically effective amounts of aflibercept, leucovorin, 5-fluorouracil (5-FU) and irinotecan, wherein the leucovorin is administered at a dosage comprised between about 200 mg/m.sup.2 and about 600 mg/m.sup.2, the 5-fluorouracil (5-FU) is administered at a dosage comprised between about 2000 mg/m.sup.2 and about 4000 mg/m.sup.2, the irinotecan is administered at a dosage comprised between about 100 mg/m.sup.2 and about 300 mg/m.sup.2 and the aflibercept is administered at a dosage comprised between about 1 mg/kg and about 10 mg/kg.

4. A method of increasing overall response rate (ORR) in a patient afflicted with CRC, said method comprising administering to said patient therapeutically effective amounts of aflibercept, leucovorin, 5-fluorouracil (5-FU) and irinotecan, wherein the leucovorin is administered at a dosage comprised between about 200 mg/m.sup.2 and about 600 mg/m.sup.2, the 5-fluorouracil (5-FU) is administered at a dosage comprised between about 2000 mg/m.sup.2 and about 4000 mg/m.sup.2, the irinotecan is administered at a dosage comprised between about 100 mg/m.sup.2 and about 300 mg/m.sup.2 and the aflibercept is administered at a dosage comprised between about 1 mg/kg and about 10 mg/kg are administered to the patient.

5. A method according to claim 1, which is safe and effective.

6. A method according to claim 1, wherein said patient has already been treated for the CRC or CRC symptom.

7. A method according to claim 6, wherein said patient has previously been treated with chemotherapy, radiotherapy or surgery.

8. A method according to claim 6, wherein said patient has previously been treated with oxaliplatin or bevacizumab.

9. A method according to claim 7, wherein the CRC or CRC symptom is resistant to or has progressed following said chemotherapy, radiotherapy or surgery.

10. A method according to claim 8, wherein the CRC is a Metastatic CRC.

11. A method according to claim 10, wherein leucovorin at a dosage of about 400 mg/m.sup.2, 5-fluorouracil (5-FU) at a dosage of about 2800 mg/m.sup.2, irinotecan at a dosage of about 180 mg/m.sup.2 and aflibercept at a dosage of about 4 mg/kg are administered to the patient.

12. A method according to claim 10, wherein leucovorin is administered intravenously at a dosage of about 400 mg/m.sup.2, 5-fluorouracil (5-FU) is administered intravenously at a dosage of about 2800 mg/m.sup.2, irinotecan is administered intravenously at a dosage of about 180 mg/m.sup.2 and aflibercept is administered intravenously at a dosage of about 4 mg/kg and wherein the combination is administered every two weeks.

13. A method according to claim 12, wherein the leucovorin, 5-fluorouracil (5-FU), irinotecan and aflibercept are administered intravenously every two weeks for a period comprised between 9 and 18 weeks.

14. A method according to claim 11, wherein the leucovorin is administered intravenously immediately after aflibercept administration.

15. A method according to claim 11, wherein the leucovorin is administered intravenously immediately after aflibercept administration over a period of about 2 hours.

16. A method according to claim 11, wherein the irinotecan is administered intravenously immediately after aflibercept administration.

17. A method according claim 16, wherein the irinotecan is administered intravenously immediately after aflibercept administration over a period of about 90 minutes.

18. A method according to claim 11, wherein the 5-fluorouracil (5-FU) is administered immediately after aflibercept administration.

19. A method according to claim 11, wherein a first quantity of 5-fluorouracil (5-FU) is administered intravenously immediately after aflibercept administration and a second quantity of 5-FU is administered intravenously after the first quantity in continuous infusion.

20. A method according to claim 19, wherein about 400 mg/m.sup.2 of 5-fluorouracil (5-FU) is administered intravenously over a period of 2 to 4 minutes after aflibercept administration and wherein 2400 mg/m.sup.2 of 5-FU is administered intravenously over almost 46 hours after the administration of the 400 mg/m.sup.2 in continuous infusion.

Description

BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS

(1) FIG. 1: Aflibercept amino acid sequence (SEQ ID NO:1)

(2) FIG. 2: Overall survival (months)—Kaplan-Meier curves by treatment group—ITT population

(3) FIG. 3: Overall survival (months)—Subgroup analyses (forest plot)—By stratification factors as per IVRS—ITT population

(4) FIG. 4: Overall survival (months)—Subgroup analyses (forest plot)—By patient demographics—ITT population

(5) FIG. 5: Overall survival (months)—Subgroup analyses (forest plot)—By baseline characteristics—ITT population

(6) FIG. 6: PFS based on tumor assessment by the IRC (months)—Subgroup analysis (forest plot)—By stratification factors as per IVRS—ITT population

DETAILED DESCRIPTION OF THE INVENTION

(7) The following example illustrates a combination according to the invention.

(8) EFC10262 (VELOUR)/A Multinational, Randomized, Double-blind Study, Comparing the Efficacy of Aflibercept Once Every 2 Weeks versus Placebo in Patients with Metastatic Colorectal Cancer (MCRC) Treated with Irinotecan/5-FU Combination (FOLFIRI) after failure of an oxaliplatin based regimen

(9) EFC10262 was designed as a randomized, double-blind, multi-centre study comparing aflibercept at 4 mg/kg to placebo, in combination with Irinotecan and 5 Fluorouracil combination (FOLFIRI) given intravenously every 2 weeks as second line treatment for patients with metastatic colorectal cancer (MCRC) after failure of an oxaliplatin based regimen. Each randomized patient was to be treated until disease progression, death, or unacceptable toxicity.

(10) The primary objective of EFC10262 was to demonstrate improvement in overall survival (OS) for aflibercept+FOLFIRI compared to placebo+FOLFIRI. The predefined statistical significance level for this final analysis was 0.0466 after adjusting the type I error spent for the two interim analyses using the O'Brien-Fleming spending function.

(11) The study included one formal interim analysis, planned for the purpose of efficacy, when 561 death events (65% information time) had occurred. Upon request of the independent Data Monitoring Committee (DMC), an additional interim analysis of OS was performed to provide an early evaluation of the benefit-risk ratio, when 315 death events (36.5% information fraction) had occurred.

(12) A total of approximately 863 deaths were required to detect 20% hazard rate reduction in OS with 90% power using the two-sided log rank test at an overall 0.0499 alpha level. The median survival times was expected to be 11 months for the control group. The overall alpha level was split between overall survival (0.0499) and progression-free survival as a secondary efficacy endpoint (0.0001).

(13) Approximately 1200 patients (i.e. 600 patients per treatment group) were planned to be randomized. Treatment assignment was stratified according to prior therapy with bevacizumab (yes or no), and ECOG performance status (PS) (0 vs 1 vs 2).

(14) The enrolment started in November 2007 and was completed in March 2010. A total of 1226 patients were randomized. The efficacy analysis was based on all randomized patients (Intent-to-Treat (ITT) population: 614 in the placebo arm and 612 patients in the aflibercept arm). The safety analysis was based on all treated patients (safety population: 605 and 611 patients in the placebo and aflibercept arms, respectively). Treatment arms were evenly balanced for demographics, disease characteristics and prior anti-cancer treatments, including prior exposition to bevacizumab.

(15) Dosage and Schedule of Administration

(16) Patients were administered either aflibercept or placebo, depending on arm assigned. Immediately after, patients received irinotecan, 5-FU and leucovorin (FOLFIRI regimen).

(17) This treatment was repeated every 2 weeks.

(18) Aflibercept/Placebo

(19) Arm A, aflibercept: 4 mg/kg was administered IV over 1 hour on Day 1, every 2 weeks,

(20) OR

(21) Arm B, placebo: 4 mg/kg was administered IV over 1 hour on Day 1, every 2 weeks.

(22) FOLFIRI Regimen

(23) Immediately after aflibercept/placebo administration, all the patients received: Irinotecan 180 mg/m.sup.2 IV infusion in 500 mL in 5% dextrose solution in water (D5W) over 90 minutes and dextro-levogyre (dl) leucovorin 400 mg/m.sup.2 IV infusion over 2 hours, at the same time, in bags using a Y-line, followed by: 5-FU 400 mg/m.sup.2 IV bolus given over 2-4 minutes, followed by: 5-FU 2400 mg/m.sup.2 continuous IV infusion in 500 mL D5W (recommended) over 46-hours.
Results of EFC10262
Demographics and Baseline Characteristics

(24) Patient demographics and characteristics at baseline were similar the 2 treatment arms (Table 1).

(25) TABLE-US-00001 TABLE 1 Summary of patient demographics and patient characteristics at baseline - ITT population Placebo/Folfiri Aflibercept/Folfiri All (N = 614) (N = 612) (N = 1226) Gender [n(%)] Number 614 612 1226 Male 353 (57.5%) 365 (59.6%) 718 (58.6%) Female 261 (42.5%) 247 (40.4%) 508 (41.4%) Age (Years) Number 614 612 1226 Median   61.0   61.0 .sup.  61.0 Mean (SD) 60.2 (10.8) .sup.  59.5 (10.5) .sup.  59.8 (10.7) .sup.  Min:Max 19:86 21:82 19:86 Age class [n(%)] Number 614 612 1226  <65 376 (61.2%) 407 (66.5%) 783 (63.9%) ≥65 but <75 199 (32.4%) 172 (28.1%) 371 (30.3%) ≥75 39 (6.4%) 33 (5.4%) 72 (5.9%) Race [n(%)] Number 614 612 1226 Caucasian/White 523 (85.2%) 548 (89.5%) 1071 (87.4%)  Black 27 (4.4%) 16 (2.6%) 43 (3.5%) Asian/Oriental 51 (8.3%) 35 (5.7%) 86 (7.0%) Other 13 (2.1%) 13 (2.1%) 26 (2.1%) Region Number 614 612 1226 Western Europe 217 (35.3%) 208 (34.0%) 425 (34.7%) Eastern Europe 136 (22.1%) 161 (26.3%) 297 (24.2%) North America  75 (12.2%)  63 (10.3%) 138 (11.3%) South America 56 (9.1%)  62 (10.1%) 118 (9.6%)  Other countries 130 (21.2%) 118 (19.3%) 248 (20.2%) Note: Other countries = Australia, New Zeland, South Africa and Korea

(26) Disease characteristics at initial diagnosis and time from diagnosis to randomization were similar in the 2 treatment arms (Table 2).

(27) TABLE-US-00002 TABLE 2 Disease characteristics at initial diagnosis - ITT population Aflibercept/ Placebo/Folfiri Folfiri All (N = 614) (N = 612) (N = 1226) Primary site [n(%)] Number 614 612 1226 Colon 302 (49.2%) 289 (47.2%) 591 (48.2%) Recto sigmoid 136 (22.1%) 123 (20.1%) 259 (21.1%) Rectum 174 (28.3%) 197 (32.2%) 371 (30.3%) Other 2 (0.3%) 3 (0.5%) 5 (0.4%) cea & ck20 postive - 1 (0.2%) 0 1 (<0.1%) presumed colorectal primary Appendix 0 1 (0.2%) 1 (<0.1%) Colon plus appendix 0 1 (0.2%) 1 (<0.1%) Presumed colorectal, 0 1 (0.2%) 1 (<0.1%) cea positive and history of colon cancer >20 years ago Synchronous primary, 1 (0.2%) 0 1 (<0.1%) cecum and rectum Histology type [n(%)] Number 614 612 1226 Adenocarcinoma 614 (100%) 612 (100%) 1226 (100%) Time from 1.sup.st diagnosis to randomization (months) [n(%)]* Number 614 611 1225 Mean (SD) 20.88 (21.10) 20.98 (24.08) 20.93 (22.62) Median 13.67 14.62 14.26 Min:Max 2.4:214.7 2.1:325.1 2.1:325.1 *If the day of initial date of diagnosis is missing, it is considered as the first day of the month
Patient Accountability

(28) Overall, 30.4% of the randomized patients were allocated in the prior bevacizumab stratum (Table 3).

(29) TABLE-US-00003 TABLE 3 Summary of randomized patients by stratification factor (as per IVRS) - ITT population Placebo/Folfiri Aflibercept/Folfiri All Stratification factors (N = 614) (N = 612) (N = 1226) ECOG PS [n(%)] 0 350 (57.0%) 349 (57.0%) 699 (57.0%) 1 250 (40.7%) 250 (40.8%) 500 (40.8%) 2 14 (2.3%) 13 (2.1%) 27 (2.2%) Prior Bevacizumab [n(%)] Yes 187 (30.5%) 186 (30.4%) 373 (30.4%) No 427 (69.5%) 426 (69.6%) 853 (69.6%) Note: ECOG: Eastern Cooperative Oncology Group, PS: Performance Status, IVRS: Interactive Voice response System
Dosage and Duration

(30) The median overall study treatment exposure (i.e. either both study drugs aflibercept/placebo and FOLFIRI, or one of them alone) was 8.0 and 9.0 cycles in the placebo and aflibercept treatment arms, respectively (Table 4).

(31) TABLE-US-00004 TABLE 4 Summary of overall study treatment exposure - Safety population Number of cycles Placebo/Folfiri Aflibercept/Folfiri received by patient (N = 605) (N = 611) Sum 6127 6358 Mean (SD) 10.1 (8.1) 10.4 (7.6) Median 8.0 9.0 Min:Max 1:67 1:50 SD: standard deviation

(32) The median number of aflibercept/placebo infusions was 8.0 and 7.0 in the placebo and aflibercept treatment arms, respectively (Table 5). The median relative dose intensity was 83% with aflibercept as compared to 92% with placebo.

(33) TABLE-US-00005 TABLE 5 Exposure to Aflibercept/Placebo - Safety population Placebo/Folfiri Aflibercept/Folfiri (N = 605) (N = 611) Number of cycles received by patient Sum 6035 5632 Mean (SD) 10.0 (8.0) 9.2 (7.2) Median 8.0 7.0 Min:Max  1:67 1:35  1 24 (4.0%) 43 (7.0%)  2 32 (5.3%) 52 (8.5%)  3 85 (14.0%) 70 (11.5%)  4 31 (5.1%) 45 (7.4%)  5 32 (5.3%) 43 (7.0%)  6 45 (7.4%) 29 (4.7%)  7 29 (4.8%) 28 (4.6%)  8 34 (5.6%) 29 (4.7%)  9 45 (7.4%) 29 (4.7%)  10 21 (3.5%) 28 (4.6%) 11-15 112 (18.5%) 94 (15.4%) 16-20 57 (9.4%) 68 (11.1%) 21-25 28 (4.6%) 34 (5.6%) >25 30 (5.0%) 19 (3.1%) Duration of exposure to aflibercept/placebo (weeks) Number 605 611 Mean (SD) 22.3 (17.5) 21.7 (16.7) Median 18.0 17.9 Min:Max  2:135 2:85 Total cumulative dose received (mg/kg) Number 605 611 Mean (SD) 39.63 (31.65) 35.69 (27.96) Median 32.00 28.00 Min:Max  0.6:266.4  3.8:140.0 Actual dose intensity (mg/kg/week) Number 605 611 Mean (SD) 1.78 (0.25) 1.55 (0.44) Median 1.84 1.66 Min:Max 0.3:2.1 0.1:2.1  Relative dose intensity Number 605 611 Mean (SD) 0.89 (0.12) 0.78 (0.22) Median 0.92 0.83 Min:Max 0.2:1.1 0.1:1.1  Number of cycles received: Number of cycles with at least one dose infusion of aflibercept/placebo.

(34) The median number of irinotecan infusions was 8.0 and 9.0 in the placebo and aflibercept treatment arms, respectively (table 6). The median relative dose intensity was 84% in the aflibercept arm as compared to 91% in the placebo arm. Of note, two patients did not receive irinotecan; the dose was considered equal to 0 for the calculation of the cumulative dose, actual and relative dose intensity.

(35) TABLE-US-00006 TABLE 6 Exposure to irinotecan- Safety population Placebo/Folfiri Aflibercept/Folfiri (N = 605) (N = 611) Number of cycles received by patient Sum 5992 6157 Mean (SD) 9.9 (7.8) 10.1 (7.4) Median 8.0 9.0 Min:Max 1:67 1:50  1 23 (3.8%) 34 (5.6%)  2 29 (4.8%) 39 (6.4%)  3 87 (14.4%) 64 (10.5%)  4 33 (5.5%) 36 (5.9%)  5 29 (4.8%) 37 (6.1%)  6 48 (7.9%) 31 (5.1%)  7 27 (4.5%) 27 (4.4%)  8 32 (5.3%) 29 (4.8%)  9 47 (7.8%) 29 (4.8%)  10 21 (3.5%) 38 (6.2%) 11-15 114 (18.9%) 111 (18.2%) 16-20 58 (9.6%) 78 (12.8%) 21-25 31 (5.1%) 35 (5.7%) >25 25 (4.1%) 22 (3.6%) Duration of exposure to irinotecan (weeks) Number 604 610 Mean (SD) 22.2 (17.2) 23.5 (16.9) Median 18.1 21.0 Min:Max  2:135  2:105 Total cumulative dose received (mg/m.sup.2) Number 605 611 Mean (SD) 1736.30 (1355.52) 1730.37 (1273.76) Median 1440.00 1472.50 Min:Max   0.0:11948.1  0.0:9046.1 Actual dose intensity (mg/m.sup.2/week) Number 605 611 Mean (SD) 78.82 (11.74) 73.59 (13.68) Median 82.08 75.60 Min:Max 0.0:95.0 0.0:95.0 Relative dose intensity Number 605 611 Mean (SD) 0.88 (0.13) 0.82 (0.15) Median 0.91 0.84 Min:Max 0.0:1.1  0.0:1.1  Number of cycles received: Number of cycles with at least one dose infusion of irinotecan.

(36) The median number of 5-FU infusions was 8.0 and 9.0 in the placebo and aflibercept treatment arms, respectively (Table 7). The median relative dose intensity was 83% in the aflibercept arm as compared to 91% in the placebo arm. Of note, two patients did not receive 5-FU; the dose was considered equal to 0 for the calculation of the cumulative dose, actual and relative dose intensity.

(37) TABLE-US-00007 TABLE 7 Exposure to 5-FU - Safety population Placebo/Folfiri Aflibercept/Folfiri (N = 605) (N = 611) Number of cycles received by patient Sum 6030 6155 Mean (SD) 10.0 (7.9) 10.1 (7.4) Median 8.0 9.0 Min:Max 1:67 1:50  1 22 (3.6%) 35 (5.7%)  2 28 (4.6%) 39 (6.4%)  3 88 (14.6%) 63 (10.3%)  4 33 (5.5%) 35 (5.7%)  5 28 (4.6%) 37 (6.1%)  6 48 (8.0%) 32 (5.2%)  7 27 (4.5%) 28 (4.6%)  8 33 (5.5%) 28 (4.6%)  9 47 (7.8%) 29 (4.7%)  10 20 (3.3%) 39 (6.4%) 11-15 114 (18.9%) 113 (18.5%) 16-20 59 (9.8%) 77 (12.6%) 21-25 28 (4.6%) 35 (5.7%) >25 28 (4.6%) 21 (3.4%) Duration of exposure to 5-FU (weeks) Number 603 611 Mean (SD) 22.4 (17.5) 23.5 (16.9) Median 18.1 21.0 Min:Max  2:135  2:105 Total cumulative dose received (mg/m.sup.2) Number 605 611 Mean (SD) 27142.02 (21341.89) 26644.81 (19245.24) Median 22400.00 22702.44 Min:Max   0.0:185874.8  409.0:126701.4 Actual dose intensity (mg/m.sup.2/week) Number 605 611 Mean (SD) 1227.42 (190.51) 1140.36 (214.35) Median 1276.38 1165.56 Min:Max  0.0:1477.3 177.0:1491.3 Relative dose intensity Number 605 611 Mean (SD) 0.88 (0.14) 0.81 (0.15) Median 0.91 0.83 Min:Max 0.0:1.1  0.1:1.1  Number of cycles received: Number of cycles with at least one dose infusion of 5-FU.
Results of EFC10262

1. OVERALL SURVIVAL

(38) The median follow-up time at the cutoff date (7 Feb. 2011) for the ITT population was 22.28 months (FIG. 2 and Table 8). The study met its primary endpoint demonstrating a significant difference in overall survival in favor of aflibercept over placebo (stratified HR: 0.817, 95.34% Cl: 0.713 to 0.937; p=0.0032). The hazard ratio translates into a reduction of risk of death of 18.3% (95.34 Cl: 6.3% to 28.7%) with aflibercept compared to placebo. After 12 and 18 months from randomization, the estimated probabilities of being alive were 50.3% in placebo arm and 56.1% aflibercept arm, and 30.9% in placebo arm and 38.5% in aflibercept arm. Median overall survival was 13.50 months vs 12.06 months in aflibercept and placebo treatment arms, respectively. Sensitivity analyses and subgroup analyses showed a very consistent treatment effect confirming robustness of results on the primary endpoint.

(39) TABLE-US-00008 TABLE 8 Overall survival (months) - Kaplan-Meier survival estimates by treatment group- Primary analysis- Stratified according to stratification factors at randomization (IVRS) - ITT population Placebo/Folfiri Aflibercept/Folfiri Time to Event or Censoring (N = 614) (N = 612) Overall Number of death events, 460/614 (74.9%) 403/612 (65.8%) n/N (%) Median overall survival 12.06 (11.072 13.50 (12.517 (95.34% CI) (months) to 13.109) to 14.949) Number of patients at risk  3 months 573 566  6 months 485 498  9 months 401 416 12 months 286 311 18 months 131 148 24 months 51 75 Survival probability (95.34% CI)  3 months 0.935 (0.915 0.931 (0.911 to 0.955) to 0.951)  6 months 0.791 (0.759 0.819 (0.788 to 0.824) to 0.850)  9 months 0.654 (0.616 0.687 (0.650 to 0.692) to 0.725) 12 months 0.503 (0.462 0.561 (0.521 to 0.543) to 0.602) 18 months 0.309 (0.269 0.385 (0.343 to 0.348) to 0.427) 24 months 0.187 (0.149 0.280 (0.237 to 0.225) to 0.324) Stratified Log-Rank test p-value.sup.a vs Placebo/Folfiri — 0.0032 Stratified Hazard ratio (95.34% CI).sup.a vs Placebo/Folfiri — 0.817 (0.713 to 0.937) Cutoff date = 7 FEB. 2011 Median follow-up time = 22.28 in months .sup.aStratified on ECOG Performance Status (0 vs 1 vs 2) and Prior Bevacizumab (yes vs no) according to IVRS. Significance threshold is set to 0.0466 using the O'Brien-Fleming alpha spending function.
Subgroup Analyses of Overall Survival (OS)

(40) Subgroup analyses did not show any significant interaction (at the 2-sided 10% level) between treatment arms and stratification factors, indicating that the treatment effect was consistent across subgroups. This is illustrated in Table 9 and in FIGS. 3, 4 and 5.

(41) TABLE-US-00009 TABLE 9 Overall survival (months) - Summary of subgroup analyses - By stratification factors as per IVRS - ITT population Placebo/Folfiri Aflibercept/Folfiri Hazard Ratio Median (Months) Median (Months) (95.34% CI) vs P-value for (95.34% CI) (95.34% CI) Placebo/Folfiri interaction .sup.a All patients 12.1 (11.07 13.5 (12.52 0.817 (0.713 to 13.11) to 14.95) to 0.937) Prior bevacizumab No 12.4 (11.17 13.9 (12.71 0.788 (0.669 0.7231 to 13.54) to 15.64) to 0.927) Yes 11.7 (9.82 12.5 (10.78 0.862 (0.673 to 13.77) to 15.51) to 1.104) ECOG PS 0 14.1 (12.88 16.9 (14.78 0.768 (0.635 0.5668 to 16.62) to 18.79) to 0.928) 1 10.1 (9.20 10.7 (9.36 0.869 (0.71 to 11.53) to 12.35) to 1.063) 2 4.4 (1.97 2.8 (0.92 0.978 (0.43 to 10.02) to 9.82) to 2.221) Cutoff date = 7 FEB. 2011 Median follow-up time = 22.28 in months .sup.a Interaction test from the Cox proportional hazard model including the factor, treatment effect and the treatment by factor interaction

(42) Treatment effect for OS was consistent across subgroups with regards to baseline characteristics at study entry. Of note, the interaction between treatment arms and the presence of liver metastasis factor was significant at 10% level, indicating a higher treatment effect in ‘liver metastasis only’ group (HR (95.34% Cl): 0.649 (0.492 to 0.855)) than in ‘no liver metastasis, or other metastases’ group (HR (95.34% Cl): 0.868 (0.742 to 1.015)) (quantitative interaction, p=0.0899) This is illustrated in Table 10.

(43) TABLE-US-00010 TABLE 10 Overall survival (months) - Summary of subgroup analyses - By baseline characteristics - ITT population Placebo/Folfiri Aflibercept/Folfiri Hazard Ratio Median (Months) Median (Months) (95.34% CI) vs P-value for (95.34% CI) (95.34% CI) Placebo/Folfiri interaction.sup.a All patients 12.1 (11.07 13.5 (12.52 0.817 (0.713 to 13.11) to 14.95) to 0.937) Prior hypertension No 11.7 (10.41 12.7 (11.17 0.883 (0.74 0.1309 to 13.11) to 14.39) to 1.054) Yes 12.7 (10.78 15.5 (12.91 0.714 (0.577 to 14.00) to 18.56) to 0.884) Number of metastatic organs involved  >1 10.5 (9.72 12.1 (10.71 0.825 (0.692 0.6992 to 12.06) to 13.11) to 0.982) <=1 13.7 (12.29 16.0 (14.42 0.767 (0.618 to 16.30) to 20.86) to 0.953) Liver Metastasis only No 12.3 (11.07 13.2 (12.06 0.868 (0.742 0.0899 to 13.73) to 15.28) to 1.015) Yes 11.4 (9.86 14.4 (12.68 0.649 (0.492 to 12.88) to 18.04) to 0.855) Location of primary tumor Colon 10.6 (9.66 12.9 (11.50 0.739 (0.607 0.1421 to 12.06) to 16.16) to 0.899) Recto 14.1 (12.71 14.3 (12.35 1.039 (0.772 sigmoid/Other to 17.08) to 16.39) to 1.4) Rectum 12.6 (10.35 13.5 (11.93 0.806 (0.629 to 14.55) to 15.87) to 1.031) Median follow-up time = 22.28 in months .sup.aInteraction test from the Cox proportional hazard model including the factor, treatment effect and the treatment by factor interaction

2. PROGRESSION FREE SURVIVAL BASED ON TUMOR ASSESSMENT BY THE IRC

(44) The final analysis for PFS was performed at the time of the second interim analysis of OS (i.e. cut off date=6 May 2010). Improvement in progression free survival (PFS) was demonstrated in patients of the aflibercept treatment arm compared to patients in the placebo treatment arm (stratified HR: 0.758, 99.99% Cl: 0.578 to 0.995; p=0.00007). Median PFS was 6.90 months in the aflibercept arm and 4.67 months in the placebo arm (Table 11).

(45) TABLE-US-00011 TABLE 11 PFS based on tumor assessment by the IRC (months) - Kaplan-Meier survival estimates by treatment group - Stratified according to stratification factors at randomization (IVRS) - ITT population Placebo/Folfiri Aflibercept/Folfiri Time to Event or Censoring (N = 614) (N = 612) Overall Number of events, n/N(%) 454/614 (73.9%) 393/612 (64.2%) Median PFS (99.99% CI) 4.67 (4.074 6.90 (5.881 (months) to 5.552) to 7.852) Number at risk  3 months 355 420  6 months 171 247  9 months 94 99 12 months 46 43 18 months 9 7 Probability of surviving (99.99% CI)  3 months 0.664 (0.587 0.793 (0.727 to 0.741) to 0.859)  6 months 0.390 (0.306 0.573 (0.488 to 0.475) to 0.659)  9 months 0.254 (0.174 0.313 (0.222 to 0.334) to 0.404) 12 months 0.146 (0.076 0.166 (0.085 to 0.216) to 0.246) 18 months 0.043 (0.000 0.051 (0.000 to 0.091) to 0.108) Stratified Log-Rank test p-value.sup.a vs Placebo/Folfiri — 0.00007 Stratified Hazard ratio (99.99% CI).sup.a vs Placebo/Folfiri — 0.758 (0.578 to 0.995) Cutoff date = 06 MAY 2010 .sup.aStratified on ECOG Performance Status (0 vs 1 vs 2) and Prior Bevacizumab (yes vs no) according to IVRS Significance threshold is set to 0.0001.
Subgroup Analyses of Progression Free Survival

(46) Progression free survival (PFS) was analyzed in subgroups as illustrated in Table 12 and in FIG. 6. No interaction between treatment arms and stratification factors was observed (Table 12).

(47) TABLE-US-00012 TABLE 12 PFS based on tumor assessment by the IRC (months) - Summary of subgroup analyses - By stratification factors as per IVRS - ITT population Placebo/Folfiri Aflibercept/Folfiri Hazard Ratio Median (Months) Median (Months) (99.99% CI) vs P-value for (99.99% CI) (99.99% CI) Placebo/Folfiri interaction.sup.a All patients 4.7 (4.07 6.9 (5.88 0.758 (0.578 to 5.55) to 7.85) to 0.995) Prior bevacizumab No 5.4 (4.17 6.9 (5.82 0.797 (0.58 0.6954 to 6.70) to 8.15) to 1.096) Yes 3.9 (2.86 6.7 (4.76 0.661 (0.399 to 5.42) to 8.74) to 1.095) ECOG PS 0 5.4 (4.24 7.2 (6.37 0.761 (0.529 0.1958 to 6.77) to 8.87) to 1.094) 1 4.1 (2.83 5.6 (4.60 0.749 (0.494 to 5.55) to 7.46) to 1.135) 2 2.0 (1.18 2.7 (0.53 0.618 (0.11 to 5.75) to 12.88) to 3.476) Cutoff date = 06 MAY 2010 .sup.aInteraction test from the Cox proportional hazard model including the factor, treatment effect and the treatment by factor interaction

(48) For PFS, no significant interaction was shown between treatment arms and demographic variables or regions.

(49) Treatment effect for PFS was consistent across subgroups with regards to baseline characteristics at study entry. Of note, the interaction between treatment arms and the presence of liver metastasis factor, that was noted on OS, was also significant at 10% level, indicating a higher treatment effect ‘in liver metastasis only’ group (HR (99.99% Cl): 0.547 (0.313 to 0.956)) than in ‘no liver metastasis, or other metastases’ group (HR (99.99% Cl): 0.839 (0.617 to 1.143)) (quantitative interaction, p=0.0076).

(50) Results of the two sensitivity analyses for PFS were consistent with those of the primary PFS analysis. Moreover, adherence to the protocol-defined schedule for tumor assessment was assessed and showed no imbalance between treatment arms.

3. OVERALL RESPONSE RATE

(51) Overall response rate—IRC reviewed—was significantly higher in the aflibercept treatment arm when compared to the placebo treatment arm: 19.8% (95% Cl: 16.4% to 23.2%) vs 11.1% (95% Cl: 8.5% to 13.8%) respectively (p=0.0001) (Table 13).

(52) TABLE-US-00013 TABLE 13 Summary of overall objective response rate by IRC - Evaluable patient population for response rate Placebo/Folfiri Aflibercept/Folfiri (N = 530) (N = 531) Best Overall Response [n(%)] Complete response 2 (0.4%) 0 Partial response 57 (10.8%) 105 (19.8%) Stable disease 344 (64.9%) 350 (65.9%) Progressive disease 114 (21.5%) 55 (10.4%) Not evaluable 13 (2.5%) 21 (4.0%) Overall Response Responders (Complete 59 (11.1%) 105 (19.8%) response or Partial response) 95% CI.sup.a 8.5% to 13.8% 16.4% to 23.2% Stratified Cochran-Mantel- Haenszel test p-value.sup.b Vs Placebo/Folfiri — 0.0001 .sup.aestimated by Normal approximation .sup.bStratified on ECOG Performance Status (0 vs 1 vs 2) and Prior Bevacizumab (yes vs no) according to IVRS.

4. FURTHER ANTI-CANCER THERAPY

(53) Overall 60% of patients in both treatment groups received further antitumor therapies (Table 14).

(54) TABLE-US-00014 TABLE 14 Summary of first further anti-cancer therapies - ITT population Placebo/Folfiri Aflibercept/Folfiri (N = 614) (N = 612) At least one further therapy [n(%)] Yes 366 (59.6%) 364 (59.5%) No 248 (40.4%) 248 (40.5%) Type of first further therapy [n(%)] Systemic anti-cancer treatment 303/366 (82.8%) 296/364 (81.3%) Radiotherapy 43/366 (11.7%) 34/364 (9.3%) Surgery 20/366 (5.5%) 34/364 (9.3%) Time from last IV to first further systemic anti-cancer therapy (months).sup.a Number 297 293 Mean (SD) 1.87 (1.71) 2.37 (2.45) Median 1.35 1.58 Min:Max 0.3:14.0 0.2:20.5 Time from last IV to first further radiotherapy (months).sup.a Number 43 33 Mean (SD) 3.02 (3.86) 3.25 (3.38) Median 1.31 2.07 Min:Max 0.4:16.5 0.6:14.6 Time from last IV to first further surgery (months).sup.a Number 20 34 Mean (SD) 1.62 (1.41) 2.42 (2.08) Median 1.15 1.48 Min:Max 0.4:7.2  0.2:8.5  Systemic anti-cancer therapies include chemotherapy and biologies. Only the earliest date of further therapy in each category (systemic anti-cancer treatment, radiotherapy or surgery) is kept .sup.aTime from last IV to first futher therapy is not calculated for patients randomized but not treated.

(55) About 32% of patients in each group receive further anticancer treatment that includes a “biologic (Table 15).

(56) TABLE-US-00015 TABLE 15 Summary of all further anti-cancer therapies - ITT population Placebo/Folfiri Aflibercept/Folfiri (N = 614) (N = 612) Any further therapy 366 (59.6%) 364 (59.5%) Surgery 31 (5.0%) 47 (7.7%) Radiotherapy 81 (13.2%) 79 (12.9%) Systemic anti-cancer treatment 329 (53.6%) 329 (53.8%) Biologies/Small molecules 197 (32.1%) 195 (31.9%) Cetuximab 91 (14.8%) 108 (17.6%) Bevacizumab 75 (12.2%) 55 (9.0%) Panitumumab 52 (8.5%) 52 (8.5%) Other 14 (2.3%) 21 (3.4%) Chemotherapy 297 (48.4%) 287 (46.9%) Fluoropyrimidine 233 (37.9%) 223 (36.4%) Irinotecan 160 (26.1%) 174 (28.4%) Other 79 (12.9%) 71 (11.6%) Oxaliplatin 66 (10.7%) 53 (8.7%) Other.sup.a 6 (1.0%) 5 (0.8%) .sup.ainclude patients randomized in placebo control trials for whom exact nature of the treatment is unknown A patient can be counted both in chemotherapy and biologies (categories can not be added).

5. SAFETY

(57) Adverse Events

(58) Treatment emergent adverse events, all grades, were reported in nearly 100% of the patients in both treatment arms, whereas occurrence of grade 3-4 events was greater in the aflibercept treatment arm (83.5% vs 62.5%).

(59) The rate of permanent discontinuation of study treatment due to adverse events was higher in the aflibercept treatment arm (26.8% vs 12.1%). A similar pattern was observed for premature treatment discontinuation due to adverse events (19.5% vs 2.8%). Premature treatment discontinuation corresponds to an earlier discontinuation of either FOLFIRI, aflibercept/placebo being continued, or aflibercept/placebo, FOLFIRI being continued.

(60) Within 30 days of last dosing, respectively 37 (6.1%) and 29 (4.8%) patients in the aflibercept and placebo arm, respectively, experienced, adverse events that eventually led to death within 30 days (28 vs 17 in the aflibercept and placebo arm, respectively) or after 30 days (9 vs 12 in the placebo and aflibercept arm, respectively) of last dosing. These included death due to disease progression.

(61) A summary of safety data is illustrated in Table 16 and Table 17.

(62) TABLE-US-00016 TABLE 16 Summary of the most frequent TEAEs: incidence ≥20% in aflibercept arm or (incidence <20% in aflibercept arm and Δ all grades ≥5%) - Safety population % of patients (in Placebo/Folfiri Aflibercept/Folfiri the safety N = 605 N = 611 Δ≥10% 5 ≤ Δ < 10 Δ≥2% population) All Gr Gr 3/4 All Gr Gr 3/4 all Gr all Gr Gr 3/4 Incidence ≥20% (aflibercept arm) Diarrhea 56.5 7.8 69.2 19.3 X X (PT) Asthenic 50.2 10.6 60.4 16.9 X X condition (HLT) Stomatitis & 34.9 5.0 54.8 13.7 X X ulceration (HLT) Nausea (PT) 54.0 3.0 53.4 1.8 Infections 32.7 6.9 46.2 12.3 X X (SOC) Hypertension 10.7 1.5 41.4 19.3 X X (grouping) GI and 29.1 3.3 34.0 5.4 abdominal pains (HLT) Vomiting 33.4 3.5 32.9 2.8 (PT) Decrease 23.8 1.8 31.9 3.4 X appetite (PT) Weight 14.4 0.8 31.9 2.6 X decrease (PT) Epistaxis 7.4 0 27.7 0.2 X (PT) Alopecia 30.1 NA 26.8 NA (PT) Dysphonia 3.3 0 25.4 0.5 X (PT) Musculoskeletal & 21.2 2.3 23.1 1.3 connective pain & discomfort (HLT) Constipation 24.6 1.0 22.4 0.8 (PT) Headache 8.8 0.3 22.3 1.6 X (PT) Incidence <20% (aflibercept arm) and Δ all grades ≥5% Palmar 4.3 0.5 11.0 2.8 X plantar erythrodysa esthesia (PT) Dehydration 3.0 1.3 9.0 4.3 X (PT) Skin 2.8 0 8.2 0 X hyperpigmentation (PT) Medra classification: SOC (system organ class), HLT (high level term), PT (Preferred term). Grouping: grouping of selected PTs Δ: difference in incidence in aflibercept arm compared to placebo

(63) TABLE-US-00017 TABLE 17 Overview of safety, number (%) of patients - Safety population Placebo/Folfiri Aflibercept/Folfiri (N = 605) (N = 611) Patients with any TEAE 592 (97.9%) 606 (99.2%) Patients with any grade 3-4 TEAE 378 (62.5%) 510 (83.5%) Patients with any serious TEAE 198 (32.7%) 294 (48.1%) Patients with any TEAE 29 (4.8%) 37 (6.1%) leading to death Patients with any related  3 (0.5%)  6 (1.0%) TEAE leading to death Patients with any TEAE  73 (12.1%) 164 (26.8%) leading to permanent treatment discontinuation Patients with any TEAE 17 (2.8%) 119 (19.5%) leading to premature treatment discontinuation Note: Adverse Events are reported using MedDRA version MEDDRA13.1 and graded using NCI CTC Version 3.0.

5. CONCLUSIONS

(64) The study met its primary endpoint, with a significant improvement in overall survival in the aflibercept arm when compared to placebo.

(65) In addition, a significant improvement was demonstrated on secondary efficacy endpoints (PFS and RR).

(66) The safety profile was qualitatively consistent with that of anti VEGF treatment with enhancement of known toxicities of the background chemotherapy (such as diarrhea, stomatitis, infections, neutropenia/neutropenic complications).