HK1189506B - Composition comprising aflibercept, folinic acid, 5-fluorouracil (5-fu) and irinocetan (folfiri) - Google Patents

Description

The present invention relates to combinations of aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan which are therapeutically useful in the treatment of Colorectal Cancer (CRC) and in particular metastatic Colorectal Cancer (CRC).

Colorectal cancers are among the most frequent tumor types in the western countries, second to breast in women and third to lung and prostate in males. The end prognosis is dependent upon the extent of the disease. The five year survival rate in early localized stage of about 90%, decreased to approximately 60-65% after spread to adjacent organ(s) or lymph nodes and is of less than 10% after spread to distant sites.

When diagnosed before nodal involvement treatment is usually limited to surgical resection (and radiotherapy for patients with rectal cancer) and potential participation to clinical trials for adjuvant therapy. Patients with nodal involvement are candidates for adjuvant chemotherapy following initial surgery in the attempt to prevent metastatic recurrence of the disease. Once spread to distant sites treatment essentially consists of palliative chemotherapy.

About 75 to 80% of all the patients with colorectal carcinoma will present at a stage when all gross carcinoma can be surgically removed. However, almost half of these patients will ultimately die from metastatic disease. Furthermore 20 to 25 % of the patients present with metastatic disease at diagnosis. Once metastases are present median overall survival with available combination therapy is around 20 months.

Over the past decades 5-Fiuorouracil (5-FU) has remained the mainstay of the chemotherapy in colorectal cancer. During years the major determinant in the treatment of colorectal cancer patients has been the improvement in the schedules of 5-FU administration.

Among these, the bimonthly regimen (LV5FU2) of 5-FU given as bolus/infusion over 2 days has been shown to be superior to the monthly 5 day bolus regimen (Mayo regimen) in terms of response rate (RR) (32.6% vs 14.4%), in terms of progression free survival (PFS) (27.6 vs 22.0 weeks), and safety (de Gramont et al, Journal of Clinical Oncology 1997;15(2):808-815).

However, no statistically significant improvement in the overall survival (OS) was seen until development, starting in the beginning of nineties, of two novel cytotoxic agents, oxaliplatin, a DACH platinum, and the topoisomerase I inhibitor, irinotecan. With each of these two new agents median overall survival in the first line metastatic setting reached 15 to 19 months in multiple Phase III trials.

In a study, published in 2004 by Tournigand et al. (Journal of Clinical Oncology 2004;22(2):229-237), where these two drugs were administered in sequence in the same protocol, as first then second line treatment in metastatic colorectal cancer patients, the threshold of 20 months median overall survival was crossed whatever was the order of the treatment sequence.

Aflibercept is synthesized as a fusion protein comprising the signal sequence of VEGFR1 fused to the D2 Ig domain of the VEGFR1 receptor, itself fused to the D3 Ig domain of the VEGFR2 receptor, in turn fused to the Fe domain of IgG1Aflibercept is also referred to as as VEGFR1 R2-Fc.DELTA.C1 or Flt1D2.Fik1D3.Fc.DELTA.C1.

The amino acid sequence (SEQ ID W1) of Aflibercept is illustrated in Figure 1 and is also shown inter alia in FIG. 24) of patent application WO 00/75319 .

5-fluorouracil (5-FU or f5U) is a drug that is a pyrimidine analog which is used in the treatment of cancer. It is a suicide inhibitor and works through irreversible inhibition of thymidylate synthase. It belongs to the family of drugs called antimetabolites.

Folinic acid or leucovorin is an adjuvant to cancer chemotherapy used in combination with 5-fluorouracil.

Irinotecan is a drug used for the treatment of cancer. Irinotecan is a topoisomerase 1 inhibitor, which prevents DNA from unwinding.

FOLFIRI is the combination of folinic acid, 5-fluorouracil (5-FU) and irinotecan and will be used throughout the document.

In a phase I study (TCD6118) aflibercept was administered IV in combination with irinotecan (180 mg/m² on day 1), leucovorin (200 mg/m² on day 1 and day 2), and 5-FU (bolus/infusional 400/600 mg/m² on day 1 and day 2), every 2 weeks in patients with advanced solid malignancies. The aflibercept 4 mg/kg dose every 2 weeks was considered to be the optimum dose.

In a phase II trial (NCI7498) aflibercept was administered in previously treated patients with metastatic colorectal cancer. This trial showed that aflibercept is well tolerated in pre-treated patients with MCRC. The conclusions are that based on the study results, studies of aflibercept as single agent or in combination should be explored (Tang et al, J Clin Oncel 26: 2008 (May 20 suppl; abstr 4027).

But the results provided in these two studies provided no insight as to efficacy.

Furthermore a phase III trial of aflibercept in metastatic pancreatic cancer was discontinued in 2009 and in 2011 the data of a phase III trial evaluating aflibercept for the second-line treatment of non-small cell lung cancer (NSCLC) showed that adding aflibercept to the chemotherapy drug docetaxel did not meet the pre-specified criteria for the primary endpoint of improvement in overall survival compared with a regimen of docetaxel plus placebo.

A summary of the clinical trial EFC10262 ("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") has been published on February 17, 2011 on the web site "clinicaltrials.gov". It indicates that the enrollment of patients is anticipated but no result of the trial is given in this summary.

It has now been found, and this is the subject of the present invention, that the effectiveness of aflibercept on Overal Survival (OS) in patients with Colorectal Cancer (CRC) can be significantly improved when it is administered in combination with FOLFIRI.

It has also been found, and this is another subject of the present invention, that the effectiveness of aflibercept on Progression Free Survival (PFS) in patients with Colorectal Cancer (CRC) can be significantly improved when it is administered in combination with FOLFIRI.

It has also been found, and this is yet another subject of the present invention, that the effectiveness of aflibercept on Overal Response Rate (ORR) in patients with Colorectal Cancer (CRC) can be significantly improved when it is administered in combination with FOLFIRI.

The invention relates to methods, compositions and articles as disclosed herein.

In one aspect the invention provides for a use for treating Colorectal Cancer (CRC) or Colorectal Cancer (CRC) symptom in a patient in need thereof, said use comprising administering to said patient therapeutically effective amounts of aflibercept and FOLFIRI. This method is safe and effective.

Also disclosed is 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 and FOLFIRI.

Also disclosed is 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 and FOLFIRI.

Also disclosed is 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 and FOLFIRI.

In a further embodiment the invention provides a use according to any one of the former embodiments wherein said patient has already been treated for the CRC or CRC symptom (second-line treatment).

In a specific embodiment CRC is a Metastatic Colorectal Cancer.

In a further embodiment the invention provides for a use according to any one of the previous embodiments wherein said patient has previously been treated with chemotherapy, radiotherapy or surgery. In an embodiment said patient has failed chemotherapy, radiotherapy or surgery.

In a further embodiment the invention provides a use according to any one of previous embodiments wherein said patient has previously been treated with therapy based on oxaliplatin or on bevacizumab.

In an embodiment said patient has failed therapy based on oxaliplatin or on bevacizumab.

In a further embodiment the invention provides a use wherein folinic acid at a dosage comprised between about 200 mg/m² and about 600 mg/m² , 5-fluorouracil (5-FU) at a dosage comprised between about 2000 mg/m² and about 4000 mg/m² , irinotecan at a dosage comprised between about 100 mg/m² and about 300 mg/m² and aflibercept at a dosage comprised between about 1 mg/kg and about 10 mg/kg are administered to patient.

In the present application the dosage of folinic acid indicated should be understood as the dosage of the racemate of folinic acid, i.e. comprising the D and L forms. Should only the L form be used the dosage should be half of the dosage indicated for the racemate.

In other words a dosage of folinic acid of about 200 mg/m² as indicated in the present application corresponds to about 200 mg/m² of racemate and about 100 mg/m² of L form.

In a further embodiment the invention provides a use wherein folinic acid at a dosage of about 400 mg/m² , 5-fluorouracil (5-FU) at a dosage of about 2800 mg/m² , irinotecan at a dosage of about 180 mg/m² and aflibercept at a dosage of about 4 mg/kg are administered to patient.

In a sixth feature the invention provides a method wherein said patient receives intravenous folinic acid at a dosage comprised of about 400 mg/m² , intravenous 5-fluorouracil (5-FU) at a dosage of about 2800 mg/m² , intravenous irinotecan at a dosage comprised of about 180 mg/m² and intravenous aflibercept at a dosage of about 4 mg/kg every two weeks.

In a further embodiment the invention provides a use wherein said patient receives intravenous folinic acid, intravenous 5-fluorouracil (5-FU), intravenous irinotecan and intravenous aflibercept every two weeks for a period comprised between about 9 and about 18 weeks.

In a further embodiment the invention provides a use wherein said patient receives intravenous folinic acid immediately after aflibercept administration.

In further embodiment the invention provides a use wherein said patient receives intravenous irinotecan immediately after aflibercept administration.

In a further embodiment the invention provides a use wherein said patient receives intravenous irinotecan immediately after aflibercept administration over almost 90 minutes.

In another embodiment the invention provides a use wherein said patient receives intravenous 5-fluorouracil (5-FU) immediately after aflibercept administration.

In another embodiment the invention provides a use wherein said patient receives a first quantity of intravenous 5-fluorouracil (5-FU) immediately after aflibercept administration and a second quantity in continous infusion.

In another embodiment the invention provides a use wherein said patient receives about 400 mg/m² of intravenous 5-fluorouracil (5-FU) over about 2 to 4 minutes after aflibercept administration and 2400 mg/m² over about 46 hours after aflibercept administration in continuous infusion.

Also disclosed is a composition comprising therapeutically effective amounts of aflibercept in combination with folinic acid, 5-fluorouracil (5-FU) and irinotecan for treating patients with CRC for simultaneous administration.

Also disclosed is a composition comprising therapeutically effective amounts of aflibercept in combination with folinic acid, 5-fluorouracil (5-FU) and irinotecan for treating patients with CRC for sequential administration.

Also disclosed is a composition comprising therapeutically effective amounts of aflibercept in combination with folinic acid, 5-fluorouracil (5-FU) and irinotecan for treating patients with CRC for administration that is spaced out over a period of time so as to obtain the maximum efficacy of the combination.

Also disclosed is a composition comprising therapeutically effective amounts of aflibercept in combination with folinic acid, 5-fluorouracil (5-FU) and irinotecan and comprising a pharmaceutically acceptable carrier for treating patients with CRC.

In one embodiment of the invention the patient has liver metastases. Also disclosed is an article of manufacture comprising:

1. a) a packaging material
2. b) aflibercept, and
3. c) a label or package insert contained within said packaging material indicating that aflibercept in combination with folinic acid, 5-fluorouracil (5-FU) and irinotecan is effective for the treatment of CRC The label or package insert contained within said packaging material indicates that aflibercept in combination with FOLFIRI improves Overall Survival (OS). The label or package insert contained within said packaging material indicates that aflibercept in combination with FOLFIRI improves Progression Free Survival (PFS). The label or package insert contained within said packaging material indicates that aflibercept in combination with FOLFIRI improves Overall Response Rate (ORR).

Also disclosed is a kit for treating patients with CRC comprising:

1. a) at least one compound chosen from the list consisting of aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan; and
2. b) a label or package insert contained within said kit indicating that aflibercept is to be used in combination with folinic acid, 5-fluorouracil (5-FU) and irinotecan (FOLFIRI) or folinic acid, 5-fluorouracil (5-FU) and irinotecan (FOLFIRI) is to be used in combination with Aflibercept

Also disclosed is a kit comprising in separate containers pharmaceutical compositions for combined use in treating CRC in a patient which comprises (1) a pharmaceutical composition comprising aflibercept, (2) a pharmaceutical composition comprising folinic acid, (3) a pharmaceutical composition comprising 5-fluorouracil (5-FU) and (4) a pharmaceutical composition comprising irinotecan.

The aflibercept can be formulated as described in WO2006/104852 . The man skilled in the art may refer in particular to WO2006/104852 or to WO 00/75319 to carry out the present invention.

Figures

• Figure 1 : Aflibercept amino acid sequence (SEQ ID NO:1)
• Figure 2 : Overall survival (months)- Kaplan-Meier curves by treatment group- ITT population
• Figure 3 : Overall survival (months) - Subgroup analyses (forest plot) - By stratification factors as per IVRS - ITT population
• Figure 4 : Overall survival (months) - Subgroup analyses (forest plot) - By patient demographics - ITT population
• Figure 5 : Overall survival (months) - Subgroup analyses (forest plot) - By baseline characteristics - ITT population
• Figure 6 : PFS based on tumor assessment by the IRC (months) - Subgroup analysis (forest plot) - By stratification factors as per IVRS - ITT population

The following example illustrates a combination according to the invention.

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

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.

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.

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.

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). 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). 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.

Dosage and schedule of administration

Patients were administered either aflibercept or placebo, depending on arm assigned. Immediately after, patients received irinotecan, 5-FU and leucovorin (FOLFIRI regimen). This treatment was repeated every 2 weeks.

Aflibercept/placebo

• Arm A, aflibercept: 4 mg/kg was administered IV over 1 hour on Day 1, every 2 weeks, OR
• Arm B, placebo: 4 mg/kg was administered IV over 1 hour on Day 1, every 2 weeks.

FOLFIRI regimen

Immediately after aflibercept/placebo administration, all the patients received:

• Irinotecan 180 mg/m2 IV infusion in 500 mL in 5% dextrose solution in water (D5W) over 90 minutes and dextro-levogyre (dl) leucovorin 400 mg/m2 IV infusion over 2 hours, at the same time, in bags using a Y-line, followed by:
• 5-FU 400 mg/m2 IV bolus given over 2-4 minutes, followed by:
• 5-FU 2400 mg/m2 continuous IV infusion in 500 mL D5W (recommended) over 46-hours.

Results of EFC10262 Demographics and baseline characteristics

Patient demographics and characteristics at baseline were similar the 2 treatment arms (Table 1). Table 1 - Summary of patient demographics and patient characteristics at baseline - ITT population

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%)

Table 1 - Summary of patient demographics and patient characteristics at baseline - ITT population

Age (Years)
Number	614	612	1226
Median	61.0	61.0	61.0
Mean (SD)	60.2 (10.8)	59.5 (10.5)	59.8 (10.7)
Min : Max	19:86	21 : 82	19:86

Table 1 - Summary of patient demographics and patient characteristics at baseline - ITT population

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%)

Table 1 - Summary of patient demographics and patient characteristics at baseline - ITT population

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%)

Table 1 - Summary of patient demographics and patient characteristics at baseline - ITT population

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

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

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 - presumed colorectal primary	1 (0.2%)	0	1 (<0.1%)
- Appendix	0	1 (0.2%)	1 (<0.1%)
- Colon plus appendix	0	1 (0.2%)	1 (<0.1%)
- Presumed colorectal,cea positive and history of colon cancer>20 years ago	0	1 (0.2%)	1 (<0.1%)
- Synchronous primary, cecum and rectum	1 (0.2%)	0	1 (<0.1%)
Histology type [n(%)]
Number	614	612	1226
Adenocarcinoma	614 (100%)	612 (100%)	1226 (100%)
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

Overall, 30.4% of the randomized patients were allocated in the prior bevacizumab stratum (Table 3). Table 3 - Summary of randomized patients by stratification factor (as per IVRS) - ITT population

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%)

Table 3 - Summary of randomized patients by stratification factor (as per IVRS) - ITT population

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

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). Table 4 - Summary of overall study treatment exposure - Safety population

Number of cycles received by patient
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

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. Table 5 - Exposure to Aflibercept/Placebo - Safety population

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%)

Table 5 - Exposure to Aflibercept/Placebo - Safety population

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

Table 5 - Exposure to Aflibercept/Placebo - Safety population

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

Table 5 - Exposure to Aflibercept/Placebo - Safety population

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

Table 5 - Exposure to Aflibercept/Placebo - Safety population

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.

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. Table 6 - Exposure to irinotecan- Safety population

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
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
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.

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. Table 7 - Exposure to 5-FU - Safety population

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
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
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

The median follow-up time at the cutoff date (07 February 2011) for the ITT population was 22.28 months (Figure 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. Table 8 - Overall survival (months) - Kaplan-Meier survival estimates by treatment group- Primary analysis- Stratified according to stratification factors at randomization (IVRS) - ITT population

Overall
Number of death events, n/N(%)	460/614 (74.9%)	403/612 (65.8%)
Median overall survival (95.34% CI) (months)	12.06 (11.072 to 13.109)	13.50 (12.517 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 to 0.955)	0.931 (0.911 to 0.951)
6 months	0.791 (0.759 to 0.824)	0.819 (0.788 to 0.850)
9 months	0.654 (0.616 to 0.692)	0.687 (0.650 to 0.725)
12 months	0.503 (0.462 to 0.543)	0.561 (0.521 to 0.602)
18 months	0.309 (0.269 to 0.348)	0.385 (0.343 to 0.427)
24 months	0.187 (0.149 to 0.225)	0.280 (0.237 to 0.324)
vs Placebo/Folfiri	-
vs Placebo/Folfiri	-
Cutoff date = 7 FEBRUARY 2011
Median follow-up time = 22.28 in months

Subgroup analyses of Overall survival (OS)

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 Figures 3, 4 and 5. Table 9 - Overall survival (months) - Summary of subgroup analyses - By stratification factors as per IVRS - ITT population

All patients	12.1 (11.07 to 13.11)	13.5 (12.52 to 14.95)	0.817 (0.713 to 0.937)
Prior bevacizumab
No	12.4 (11.17 to 13.54)	13.9 (12.71 to 15.64)	0.788 (0.669 to 0.927)	0.7231
Yes	11.7 (9.82 to 13.77)	12.5 (10.78 to 15.51)	0.862 (0.673 to 1.104)
ECOG PS
0	14.1 (12.88 to 16.62)	16.9 (14.78 to 18.79)	0.768 (0.635 to 0.928)	0.5668
1	10.1 (9.20 to 11.53)	10.7 (9.36 to 12.35)	0.869 (0.71 to 1.063)
2	4.4 (1.97 to 10.02)	2.8 (0.92 to 9.82)	0.978 (0.43 to 2.221)
Cutoff date = 7 FEBRUARY 2011
Median follow-up time = 22.28 in months

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% CI): 0.649 (0.492 to 0.855)) than in 'no liver metastasis, or other metastases' group (HR (95.34% CI): 0.868 (0.742 to 1.015)) (quantitative interaction, p=0.0899) This is illustrated in Table 10. Table 10 - Overall survival (months) - Summary of subgroup analyses - By baseline characteristics - ITT population

All patients	12.1 (11.07 to 13.11)	13.5 (12.52 to 14.95)	0.817 (0.713 to 0.937)
Prior hypertension
No	11.7 (10.41 to 13.11)	12.7 (11.17 to 14.39)	0.883 (0.74 to 1.054)	0.1309
Yes	12.7 (10.78 to 14.00)	15.5 (12.91 to 18.56)	0.714 (0.577 to 0.884)
Number of metastatic organs involved
> 1	10.5 (9.72 to 12.06)	12.1 (10.71 to 13.11)	0.825 (0.692 to 0.982)	0.6992
<= 1	13.7 (12.29 to 16.30)	16.0 (14.42 to 20.86)	0.767 (0.618 to 0.953)
Liver Metastasis only
No	12.3 (11.07 to 13.73)	13.2 (12.06 to 15.28)	0.868 (0.742 to 1.015)	0.0899
Yes	11.4 (9.86 to 12.88)	14.4 (12.68 to 18.04)	0.649 (0.492 to 0.855)
Location of primary tumor
Colon	10.6 (9.66 to 12.06)	12.9 (11.50 to 16.16)	0.739 (0.607 to 0.899)	0.1421
Recto sigmoid/Other	14.1 (12.71 to 17.08)	14.3 (12.35 to 16.39)	1.039 (0.772 to 1.4)
Rectum	12.6 (10.35 to 14.55)	13.5 (11.93 to 15.87)	0.806 (0.629 to 1.031)
Median follow-up time = 22.28 in months

2. Progression free survival based on tumor assessment by the IRC

The final analysis for PFS was performed at the time of the second interim analysis of OS (i.e. cut off date = 06 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 %CI: 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). 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

Overall
Number of events, n/N(%)	454/614 (73.9%)	393/612 (64.2%)
Median PFS (99.99% CI) (months)	4.67 (4.074 to 5.552)	6.90 (5.881 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 to 0.741)	0.793 (0.727 to 0.859)
6 months	0.390 (0.306 to 0.475)	0.573 (0.488 to 0.659)
9 months	0.254 (0.174 to 0.334)	0.313 (0.222 to 0.404)
12 months	0.146 (0.076 to 0.216)	0.166 (0.085 to 0.246)
18 months	0.043 (0.000 to 0.091)	0.051 (0.000 to 0.108)
vs Placebo/Folfiri	-	0.00007
vs Placebo/Folfiri	-	0.758 (0.578 to 0.995)
Cutoff date = 06 MAY 2010
Significance threshold is set to 0.0001.

Subgroup analyses of Progression free survival

Progression free survival (PFS) was analyzed in subgroups as illustrated in Table 12 and in Figure 6. No interaction between treatment arms and stratification factors was observed (Table 12). Table 12 - PFS based on tumor assessment by the IRC (months) - Summary of subgroup analyses - By stratification factors as per IVRS - ITT population

All patients	4.7 (4.07 to 5.55)	6.9 (5.88 to 7.85)	0.758 (0.578 to 0.995)
Prior bevacizumab
No	5.4 (4.17 to 6.70)	6.9 (5.82 to 8.15)	0.797 (0.58 to 1.096)	0.6954
Yes	3.9 (2.86 to 5.42)	6.7 (4.76 to 8.74)	0.661 (0.399 to 1.095)
ECOG PS
0	5.4 (4.24 to 6.77)	7.2 (6.37 to 8.87)	0.761 (0.529 to 1.094)	0.1958
1	4.1 (2.83 to 5.55)	5.6 (4.60 to 7.46)	0.749 (0.494 to 1.135)
2	2.0 (1.18 to 5.75)	2.7 (0.53 to 12.88)	0.618 (0.11 to 3.476)
Cutoff date = 06 MAY 2010

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

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%CI): 0.547 (0.313 to 0.956)) than in 'no liver metastasis, or other metastases' group (HR (99.99%CI): 0.839 (0.617 to 1.143)) (quantitative interaction, p=0.0076).

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

Overall response rate -IRC reviewed- was significantly higher in the aflibercept treatment arm when compared to the placebo treatment arm: 19.8% (95%CI: 16.4% to 23.2%) vs 11.1% (95%CI: 8.5% to 13.8%) respectively (p=0.0001) (Table 13). Table 13 - Summary of overall objective response rate by IRC - Evaluable patient population for response rate

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 response or Partial response)	59 (11.1%)	105 (19.8%)
	8.5% to 13.8%	16.4% to 23.2%
Vs Placebo/Folfiri	-	0.0001

4. Further anti-cancer therapy

Overall 60% of patients in both treatment groups received further antitumor therapies (Table 14). Table 14 - Summary of first further anti-cancer therapies - ITT population

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%)
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
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
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 biologics. Only the earliest date of further therapy in each category (systemic anti-cancer treatment, radiotherapy or surgery) is kept

About 32% of patients in each group receive further anticancer treatment that includes a "biologic (Table 15). Table 15 - Summary of all further anti-cancer therapies - ITT population

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%)
Biologics / 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%)
6 (1.0%)	5 (0.8%)
A patient can be counted both in chemotherapy and biologics (categories can not be added).

5. Safety Adverse events

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

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.

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.

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

Diarrhea (PT)	56.5	7.8	69.2	19.3	X		X
Asthenic condition (HLT)	50.2	10.6	60.4	16.9	X		X
Stomatitis & ulceration (HLT)	34.9	5.0	54.8	13.7	X		X
Nausea(PT)	54.0	3.0	53.4	1.8
Infections (SOC)	32.7	6.9	46.2	12.3	X		X
Hypertensio n (grouping)	10.7	1.5	41.4	19.3	X		X
GI and abdominal pains (HLT)	29.1	3.3	34.0	5.4
Vomiting (PT)	33.4	3.5	32.9	2.8
Decrease appetite (PT)	23.8	1.8	31.9	3.4		X
Weight decrease (PT)	14.4	0.8	31.9	2.6	X
Epistaxis (PT)	7.4	0	27.7	0.2	X
Alopecia (PT)	30.1	NA	26.8	NA
Dysphonia (PT)	3.3	0	25.4	0.5	X
Musculoskel etal & connective pain & discomfort (HLT)	21.2	2.3	23.1	1.3
Constipation (PT)	24.6	1.0	22.4	0.8
Headache (PT)	8.8	0.3	22.3	1.6	X

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

Palmar plantar erythrodysa esthesia (PT)	4.3	0.5	11.0	2.8		X
Dehydration (PT)	3.0	1.3	9.0	4.3		X
Skin hyperpigme ntation (PT)	2.8	0	8.2	0		X
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

Table 17 - Overview of safety, number (%) of patients - Safety population

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 leading to death	29 (4.8%)	37 (6.1%)
Patients with any related TEAE leading to death	3 (0.5%)	6 (1.0%)
Patients with any TEAE leading to permanent treatment discontinuation	73 (12.1%)	164 (26.8%)
Patients with any TEAE leading to premature treatment discontinuation	17 (2.8%)	119 (19.5%)
Note : Adverse Events are reported using MedDRA version MEDDRA13.1 and graded using NCI CTC Version 3.0.

5. Conclusions

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

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

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).

SEQUENCE LISTING

• <110> SANOFI
• <120> Composition comprising aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinocetan (FOLFIRI)
• <130> FR2011-027 EXT
• <160> 1
• <170> PatentIn version 3.3
• <210> 1 <211> 431 <212> PRT <213> Artificial
• <220> <223> Aflibercept
• <400> 1

Claims (21)

1. Combination comprising aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan in therapeutically effective amounts for use for treating Colorectal Cancer (CRC) or Colorectal Cancer (CRC) symptom in a patient in need thereof.
2. A combination for use according to claim 1 wherein said patient has already been treated for the CRC or CRC symptom.
3. A combination for use according to any one of claims 1 and 2 wherein said patient has previously been treated with chemotherapy, radiotherapy or surgery.
4. A combination for use according to any one of claims 1 to 3 wherein said patient has previously been treated with therapy based on oxaliplatin or on bevacizumab.
5. A combination for use according to any one of claims 1 and 2 wherein said patient has failed with chemotherapy, radiotherapy or surgery.
6. A combination for use according to any one of claims 1 to 5 wherein the Colorectal Cancer is Metastatic Colorectal Cancer (MCRC).
7. A combination for use according to any one of claims 1 to 6 wherein aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan are administered sequentially.
8. A combination for use according to any one of claims 1 to 6 wherein aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan are administered spaced out over a period of time so as to obtain the maximum efficacy of the combination.
9. A combination for use according to any one of claims 1 to 8 wherein folinic acid at a dosage comprised between 200 mg/m² and 600 mg/m² , 5-fluorouracil (5-FU) at a dosage comprised between 2000 mg/m² and 4000 mg/m² , irinotecan at a dosage comprised between 100 mg/m² and 300 mg/m² and aflibercept at a dosage comprised between 1 mg/kg and 10 mg/kg are administered to patient.
10. A combination for use according to any one of claims 1 to 9 wherein folinic acid at a dosage of about 400 mg/m² , 5-fluorouracil (5-FU) at a dosage of about 2800 mg/m² , irinotecan at a dosage of about 180 mg/m² and aflibercept at a dosage of about 4 mg/kg are administered to patient.
11. A combination for use according to any one of claims 1 to 10 wherein folinic acid is administered intravenously at a dosage of about 400 mg/m² , 5-fluorouracil (5-FU) is administered intravenously at a dosage of about 2800 mg/m² , irinotecan is administered intravenously at a dosage of about 180 mg/m² and aflibercept is administered intravenously at a dosage of about 4 mg/kg and wherein the comination is administered every two weeks.
12. A combination for use according to any one of claims 1 to 11 wherein the folinic acid, 5-fluorouracil (5-FU), irinotecan and aflibercept are administered intravenously every two weeks for a period comprised between 9 and 18 weeks.
13. A combination for use according to any one of claims 1 to 12 wherein the folinic acid is administered intravenously immediately after aflibercept administration.
14. A combination for use according to any one of claims 1 to 13 wherein the folinic acid is administered intravenously immediately after aflibercept administration over a period of about 2 hours.
15. A combination for use according to any one of claims 1 to 14 wherein the irinotecan is administered intravenously immediately after aflibercept administration.
16. A combination for use according to any one of claims 1 to 15 wherein the irinotecan is administered intravenously immediately after aflibercept administration over a period of about 90 minutes
17. A combination for use according to any one of claims 1 to 16 wherein the 5-fluorouracil (5-FU) is administered immediately after aflibercept administration.
18. A combination for use according to any one of claims 1 to 17 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 continous infusion.
19. A combination for use according to any one of claims 1 to 18 wherein about 400 mg/m² of 5-fluorouracil (5-FU) is administered intravenously over a period of 2 to 4 minutes after aflibercept administration and wherein 2400 mg/m² of 5-FU is administered intravenously over almost 46 hours after the administration of the 400 mg/m² in continous infusion.
20. A combination for use according to any one of claims 1 to 19 wherein the patient has liver metastases.
21. A combination for use according to any one of claims 1 to 6 wherein aflibercept, folinic acid, 5-fluorouracil (5-FU) and irinotecan are administered simultaneously.