Speaker: Lisette Stork-Sloots, Sr Program Director at Agendia, discusses how their technology, MammaPrint was commercialized. Part of Dx2010, a workshop at MaRS focused on best practices and regulatory considerations for developing gene-based diagnostic and prognostic tests.

1. MammaPrint From Bench to Bedside
Lisette Stork-Sloots
Sr Program Director

2. AGENDIA AT A GLANCE
To improve the quality of life for cancer patients by
Mission providing state-of-the-art services that enable safe and
effective personalized treatment.
Founded 2003 Amsterdam, The Netherlands
Industry Molecular Diagnostics
Technology Gene Expression Profiling
2 2

3. Agendia: Milestones
Reimbursement
FDA starts to regulate FDA Clearance #2 MP Medicare
complex diagnostic RNARetain FDA
tests Clearance #3
US Launch of MP>61
MammaPrint
MammaPrint
Launch of FDA Clearance #1 Agendia Inclusion in
Foundation MammaPrint MammaPrint Inc Int. Guidelines
of Agendia USA (St. Gallen)
2003 2004 2005 2006 2007 2008 2009

4. Company
USA EU/ROW
Huntington Beach Amsterdam
California The Netherlands
! US Headquarters ! Company Headquarters
! US Sales & Marketing (2008) ! International Sales & Marketing
! Laboratory (Q1 ’09: CLIA, CAP) ! R&D
! Regulatory Affairs
! Quality Assurance
! Laboratory (CLIA, CAP, ISO
4
17025 and QSR)

5. High Quality Certified Central Labs
Huntington Beach, CA & Amsterdam, NL
Diagnosis Sampling FDA cleared assay in CLIA registered, Results
Surgery Shipping CAP and ISO 17025 accredited lab Report
1 day 5-10 days

6. Awards
MammaPrint® receives important award from the
2008
Dutch Health Minister, Ab Klink
TIME magazine “Healthcare Invention of the Year”
2007 Estee Lauder Breast Cancer Research Foundation Award
Frost & Sullivan Breast Cancer Diagnostics Award
ESMO award for translational research in
breast cancer
Agendia selected as the 25 brightest start-up companies
2006
by FEMS Business
MammaPrint® one of the 5 biggest health breakthroughs
2005
according to Oprah Winfrey
6

7. MammaPrint “From Bench to Bedside”
Research
microarray profile
Clinical validation
studies
High-throughput
lab & informatics
Regulatory
accreditation
Commercially
Guidelines available
diagnostic test
Prospective
feasibility study
Reimbursement

8. MammaPrint “From Bench to Bedside”
Research
microarray profile
Clinical validation
studies
High-throughput
lab & informatics
Regulatory
accreditation
Commercially
Guidelines available
diagnostic test
Prospective
feasibility study
Reimbursement

9. Breast cancer-10 years survival curve
Premenopausal patients, LN-
Patients, pre-menopausal, lymph-node negative

10. The Challenge:
Identify those patients who benefit from chemotherapy
Cured by surgery
Cured by hormonal therapy
Most Common Breast Cancer: T1, N0, ER+, Grade 2.
Only two patients of 100 benefit from additional chemotherapy

11. What is expression phenotyping
and how is it measured?
High Risk
Low Risk
analysis

12. Benefit of untreated patients
Profiling of the tumor
Gene expression profile identifies “low risk”
and “high risk” tumors

13. Identification of a breast cancer
prognosis profile
breast tumors (‘83-’94)
patients < 55 years
lymph node negative (LN0)
no adjuvant therapy
Unbiased full genome
gene expression analysis
70 Prognosis Reporter Genes
distant metastases no distant metastases
< 5 years in at least 5 years

14. Prognosis Classifier for Breast Cancer
70 significant prognosis genes
Good signature
Discovery:
78 tumors Van ‘t Veer et al. (2002)
threshold
Nature 415, 530-536.
Poor signature
Threshold set with 10% false negatives
91% sensitivity; 73% specificity
Metastases: white = +
Van ‘t Veer et al Nature 415, p530-536, 2002

15. MammaPrint: A 70 gene breast cancer prognosis test
good profile:
First validation:
~4% die of breast cancer
~96% survive et al. (2002)
Van de Vijver breast cancer
New England J. Med. 347, 1999-2009.
poor profile:
295 patients
~50% die of breast cancer
~50% survive breast cancer
40% good profile ; 60% poor profile

16. MammaPrint “From Bench to Bedside”
Research
microarray profile
Clinical validation
studies
High-throughput
lab & informatics
Regulatory
accreditation
Commercially
Guidelines available
diagnostic test
Prospective
feasibility study
Reimbursement

17. Independent External Validation:
MammaPrint outperforms all clinical risk assessment
High clinical risk Low clinical risk
Adjuvant on line! N=222
73%
Second validation:
Adjuvant on line! N=80
27%
Buyse et al. (2006)
27% JNCI. 98, 1183-1192.
35%
MammaPrint
MammaPrint
Low risk
High risk
302 patients
Over- Under-
treatment! treatment!
Buyse et al JNCI 2006
35% Discordant
cases!

18. Metastasis-free survival
70 gene profile MammaPrint Adjuvant!Online
10-year DMFS 10-year DMFS
1.0
1.0
90% (85%-96%) 85% (77%-94%)
0.8
0.8
10-year DMFS
10-year DMFS 76% (70%-82%)
0.6
0.6
71% (65%-78%)
Probability
Probability
0.4
0.4
Patients Events Risk group Patients Events Risk group
0.2
0.2
111 18 Gene signature low risk 80 13 Low clinical risk
191 58 Gene signature high risk 222 63 High clinical risk
0.0
0.0
0 2 4 6 8 10 12 14 0 2 4 6 8 10 12 14
Year Year
111 108 102 95 92 80 64 43 80 76 72 65 57 48 38 20
222 201 181 166 152 135 110 72
191 169 151 136 117 103 84 49 Number at risk
Number at risk
Discordant cases better predicted by MammaPrint

19. MammaPrint has been clinically validated in 2300+ patients
Purpose Year Patients (n) Reference
Discovery 2002 78 Van’t Veer et al. Nature 615
First Validation 2002 295 Van de Vijver et al. NEJM 347
Independent European Validation 2006 302 Buyse et al J NCI 17
Validation in Dutch patient cohort 2006 123 Bueno de Mesquita et al. Eur J Can 4
Prospective Implementation Study 2007 427 Bueno de Mesquito et al. Lancet Oncol. 8
Validation in US patients 2008 100 Wittner et al. Clin Cancer Res 14
Validation in core biopsies 2008 35 Mayordomo et al. ESMO Meeting
Validation in Patients with 1-3 positive LN 2008 241 Mook et al. Breast Cancer Res Treat.
Validation in postmenopausal patients 2008 148 Mook et al. (submitted) / SABCS
Validation in tamoxifen treated patients 2009 192 Kok et al. (submitted)
Validation in German patients 2009 140 Kunz et al. St. Gallen Conference
Validation in Japanese patients 2009 118 Ishitobi et al. JJCO
Predictiveness for neoadjuvant treatment 2009 167 Straver et al. Breast Cancer Res Treat.
Validation in patients with 4-9 positive LN 2009 162 Saghastchian et al. St. Gallen Conference
Meta-analysis
Predictiveness for adjuvant treatment 2009 1637 Knauer et al. Breast Cancer Res Treat.

20. MammaPrint has been clinically validated
in an international patient cohort
Validation Studies Country Reference Years
2006 2007 2008 2009
Independent European study Buyse et al J NCI 17 302
Dutch patient cohort de Mesquita et al. Eur J Can 4 123
Prospective Study de Mesquito et al. Lancet Oncol. 8 427
Core Needle biopsies Mayordomo et al. ESMO Meeting 35
Validation in US patients Wittner et al. Clin Cancer Res 14 100
Validation in 1-3 LN+ patients Mook et al. Breast Cancer Res Treat. 241
Postmenopausal patients (>61) Mook et al. (submitted) / SABCS 148
Patients treated with Tamoxifen Kok et al. (submitted) 121
German patient cohort Kunz et al. St. Gallen Conference 140
Japanese patient cohort Ishitobi et al. JJCO 118
Validation in 4-9 LN+ patients Saghastchian et al. St. Gallen Conf 168
Neoadjuvant predictive study Straver et al. Breast Cancer Res Treat 167
Predictiveness (Meta-analysis) study Knauer et al. Breast Cancer Res Treat 1,637
Neoadjuvant predictive study US Somlo et al. ASCO annual conference 68
20

21. MammaPrint “From Bench to Bedside”
Research
microarray profile
Clinical validation
studies
High-throughput
lab & informatics
Regulatory
accreditation
Commercially
Guidelines available
diagnostic test
Prospective
feasibility study
Reimbursement

22. Technology Platform: MammaPrint array
A dedicated microarray
• Produced by Agilent Technologies
• features eight identical subarrays per slide, each with 15.000 features
• 231 reporter genes , including 70 genes, printed 5x
• Plus, 495 normalization genes and std control grid with positive and negative controls
Glas et al. 2006 BMC Genomics 7; 278

23. Overview: Agendia laboratory process

24. MammaPrint is stable and reproducible
70-Gene Prognostic Assay Experiment 2
70-Gene Prognostic Assay Experiment 1
Glas et al. 2006 BMC Genomics 7; 278

25. MammaPrint is stable and reproducible
1
LRC:
0.8
Mean MPI: 0.686
0.6 Stdev: 0.033
0.4
MammaPrint Index
0.2
0
-0.2
-0.4 HRC;
Mean MPI: -0.503
-0.6
Stdev: 0.028
-0.8
LRC (n=284
HRC (n=284)
-1
Oct-2005 May-2006 Nov-2006 June-2007 Dec-2007 July-2008
Date

26. Regulatory Approval of MammaPrint
MammaPrint is the first molecular
diagnostic test cleared by FDA
ISO 17025 accredited and CE marked
for European market
CLIA registered
College of American Pathologists
(CAP) accredited
26

27. MammaPrint “From Bench to Bedside”
Research
microarray profile
Clinical validation
studies
High-throughput
lab & informatics
Regulatory
accreditation
Commercially
Guidelines available
diagnostic test
Prospective
feasibility study
Reimbursement

28. RASTER trial; an implementation study
• Implementation of MammaPrint is feasible in Dutch community hospitals
• 427 Consecutive patients with a MammaPrint result (51% LR, 49% HR)
• 30-40% Discordance between prognosis according to clinical guidelines and
MammaPrint
• Adding MammaPrint to clinical guidelines led to a treatment change in 27% of the
patients
• Less adjuvant chemotherapy would be given when the data based on
MammaPrint alone are used, which might spare patients from adverse effects.
Bueno-de-Mesquita et al., Lancet Oncology, Vol 8, 2007

29. MammaPrint “From Bench to Bedside”
Research
microarray profile
Clinical validation
studies
High-throughput
lab & informatics
Regulatory
accreditation
Commercially
Guidelines available
diagnostic test
Prospective
feasibility study
Reimbursement

30. Health Economics – “The Big Picture”
In order to bring a product to market successfully
two basic elements that are key;
1) Legal requirements (e.g. FDA clearance, CE mark)
- Is the product safe and effective? (technical/clinical validity)
2) Reimbursement
- Is it reasonable and necessary? (clinical utility)

31. Health Economics – “The Big Picture”
F1
Payment
Reimbursement
E1 E2 E3
Coverage Coding Pricing
Evidence Dossier
D1 D2
Private Payers Governmental Payers
o Clinical Utility (demand & impact)
C1 C2 C3 o Clinical Validation
Key Opinion Professional Patient
Leaders Societies Advocacy
o Technical Validation
B1 o Health Economics
Evidence dossier
A1
Basic Requirements

32. Health Economics: definitions
! LY: measure of gains or losses in quantity of life (mortality)
! QALY: A QALY combines gains or losses in both quantity of life
(mortality) and quality of life (morbidity)
! ICER: Incremental Cost-Effectiveness Ratio between the two
alternative programs, the difference in costs (incremental cost) is
compared to their difference in outcomes (incremental effect) by
dividing the former by the latter

33. Base Case Model: Results
Total Cost Effect Incremental Cost Incremental ICER ($)
($) Effect
($)
Life Years (LY)
AS 162 140 21.596 - - -
MP 163 580 21.739 1 440 0.143 10 059
Quality-Adjusted Life Years (QALY)
AS 162 140 21.065 - - -
MP 163 580 21.218 1 440 0.153 9 428
! The overall costs of MP-guided treatment was $1,140 higher than AS guided
treatment
! The overall LY and QALY gains associated with the use of MP were 0.14 and
0.15 year, respectively
! The ICER was $10, 059 per LY and $9,428 per QALY, well within the commonly
accepted threshold values (e.g., $50, 000-$100, 000 per QALY)
33

34. MammaPrint is included in the International St. Gallen
Expert Consensus Recommendations
“In an important change from the previous St. Gallen conference, the
Panel supported the use of a validated multi-gene profiling assay,
if readily available, as an adjunct to high quality phenotyping of
breast cancer in cases in which the indication for adjuvant chemotherapy
remained uncertain.”
Goldhirsch et al. (2009) Annals of Oncology (published online June17)

35. THANK YOU!