CABOZANTINIB

	COMETRIQ™ is indicated for the treatment of patients with progressive, metastatic medullary thyroid cancer (MTC).

COMETRIQ™ inhibits the activity of tyrosine kinases including RET, MET, and VEGFRs. These receptor tyrosine kinases are involved in both normal cellular function and in pathologic processes such as oncogenesis, metastasis, tumor angiogenesis, and maintenance of the tumor microenvironment.

COMETRIQ was approved based on a pivotal trial in metastatic MTC patients (N=330) who were required to have radiographic evidence of actively progressive disease within 14 months prior to study entry.

• Significantly prolonged progression-free survival (PFS) vs placebo (HR=0.28; 95% CI: 0.19, 0.40; P<0.0001) — Median PFS was 11.2 months with COMETRIQ vs 4.0 months with placebo • Objective response rate (ORR) was 27% with COMETRIQ vs 0% with placebo (P<0.0001) — Median duration of tumor response was 14.7 months (95% CI: 11.1, 19.3) • Adverse reactions occurring in ≥25% of patients treated with COMETRIQ and more frequently than with placebo (≥5% between-arm difference) in order of decreasing frequency were: diarrhea, stomatitis, palmar-plantar erythrodysesthesia syndrome (PPES), decreased weight, decreased appetite, nausea, fatigue, oral pain, hair color changes, dysgeusia, hypertension, abdominal pain, and constipation; the most common laboratory abnormalities (>25%) were increased AST, increased ALT, lymphopenia, increased alkaline phosphatase, hypocalcemia, neutropenia, thrombocytopenia, hypophosphatemia, and hyperbilirubinemia.

Exelixis® Access Services comprehensive support program* For you and your patients — call 1-855-253-EASE (1-855-253-3273) 8:00 am to 11:00 pm ET, Monday to Friday

Easing access to COMETRIQ with a full range of services, provided by trained professionals, to meet the needs of healthcare professionals in prescribing and of patients in obtaining COMETRIQ.

• Access and reimbursement support (including benefit coverage and appeals) • Assistance with coding information and obtaining COMETRIQ • Financial assistance to enroll eligible patients into available programs (Co-pay Assistance, Patient Assistance, and Alternate Funding Investigation)

* This description of the Exelixis Access Services program is for informational purposes only. Exelixis makes no representation or guarantee concerning reimbursement or coverage for any service or item. Information provided through the Exelixis Access Services program does not constitute medical or legal advice and is not intended to be a substitute for a consultation with a licensed healthcare provider, legal counsel, or applicable third-party payer(s). Exelixis reserves the right to modify the program at any time without notice. Financial aid for people in need may be available from certain government programs and charities. These include state pharmaceutical assistance programs (SPAPs), Medicaid, Medicare Part D, low-income subsidies, and charitable foundations. An Exelixis Access Services program specialist can explain these options to you.

IMPORTANT SAFETY INFORMATION

	BOXED WARNING: PERFORATIONS AND FISTULAS, and HEMORRHAGE See full prescribing information for complete boxed warning. Perforations and Fistulas: Gastrointestinal perforations occurred in 3% and fistula formation in 1% of COMETRIQ-treated patients. Discontinue COMETRIQ in patients with perforation or fistula. Hemorrhage: Severe, sometimes fatal, hemorrhage including hemoptysis and gastrointestinal hemorrhage occurred in 3% of COMETRIQ-treated patients. Monitor patients for signs and symptoms of bleeding. Do not administer COMETRIQ to patients with severe hemorrhage.

ADDITIONAL IMPORTANT SAFETY INFORMATION Gastrointestinal (GI) perforations (3%) and GI fistulas (1%), all serious, were reported with COMETRIQ, including 1 (<1%) fatal GI fistula. Non-GI fistulas including tracheal/esophageal were reported (4%), including 2 (1%) fatal events. Monitor patients for symptoms of perforations and fistulas. Discontinue COMETRIQ in patients who experience a perforation or a fistula.

Serious and sometimes fatal hemorrhage occurred with COMETRIQ. The incidence of Grade ≥3 hemorrhagic events was higher with COMETRIQ (3%) than with placebo (1%). Do not administer COMETRIQ to patients with a recent history of hemorrhage or hemoptysis.

Increased incidence of thrombotic events (venous thromboembolism: 6% vs 3%; arterial thromboembolism: 2% vs 0%) was reported with COMETRIQ vs placebo, respectively. Discontinue COMETRIQ in patients who develop an acute myocardial infarction or any other clinically significant arterial thromboembolic complication.

Wound complications have been reported with COMETRIQ. Stop treatment with COMETRIQ ≥28 days prior to scheduled surgery. Resume COMETRIQ therapy after surgery based on clinical judgment of adequate wound healing. Withhold COMETRIQ in patients with dehiscence or wound healing complications requiring medical intervention.

Increased incidence of treatment-emergent hypertension, stage 1 or 2 (modified JNC† criteria), was identified with COMETRIQ (61% vs 30% with placebo). Monitor blood pressure prior to initiation and regularly during COMETRIQ treatment. Withhold COMETRIQ for hypertension that is not adequately controlled with medical management; when controlled, resume COMETRIQ at a reduced dose. Discontinue COMETRIQ for severe hypertension that cannot be controlled with anti-hypertensive therapy.

Osteonecrosis of the jaw (ONJ) occurred with COMETRIQ (1%). ONJ can manifest as jaw pain, osteomyelitis, osteitis, bone erosion, tooth or periodontal infection, toothache, gingival ulceration or erosion, persistent jaw pain or slow healing of the mouth or jaw after dental surgery. Perform an oral examination prior to initiation of COMETRIQ and periodically during therapy. Advise patients regarding good oral hygiene practices. For invasive dental procedures, withhold COMETRIQ treatment for ≥28 days prior to scheduled surgery, if possible.

Palmar-plantar erythrodysesthesia syndrome (PPES) occurred (50%) with COMETRIQ and was severe (Grade ≥3) in 13% of patients. Withhold COMETRIQ in patients who develop intolerable Grade 2 PPES or Grade 3-4 PPES until improvement to Grade 1; resume COMETRIQ at a reduced dose.

Proteinuria was observed in 4 (2%) patients receiving COMETRIQ, including 1 with nephrotic syndrome, compared with 0 patients receiving placebo. Monitor urine protein regularly during COMETRIQ treatment. Discontinue COMETRIQ in patients who develop nephrotic syndrome.

Reversible posterior leukoencephalopathy syndrome (RPLS) occurred in 1 (<1%) patient. Perform an evaluation for RPLS in any patient presenting with seizures, headache, visual disturbances, confusion, or altered mental function. Discontinue COMETRIQ in patients who develop RPLS.

Avoid administration of COMETRIQ with agents that are strong CYP3A4 inducers or inhibitors.

COMETRIQ is not recommended for use in patients with moderate or severe hepatic impairment.

COMETRIQ can cause fetal harm when administered to a pregnant woman. If this drug is used during pregnancy, or if the patient becomes pregnant during therapy, the patient should be apprised of the potential hazard to the fetus.

The COMETRIQ dose was reduced in 79% of patients vs 9% for placebo.

†Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

For the full Prescribing Information, including Boxed Warning, please click here.

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DRUGS ON THE MOVE

 DRUGS  ON THE MOVE

1.   In Breast cancer

-Everolimus
-Pertuzumab
-T-DM-1

2.   In Prostate  cancer

-Abiraterone (Zytiga)
-Enzalutmide (Xtandi)
-Alpharadin (Radium 223)

3.   Other
-Cabozantinib
-Orteronel
-Curtisen
-Tasquinimod

4.   Melanoma

-Dabrafenib
-Trametinib
-GDC- 0973
-Vemurafenib (Zelboraf)
-Nivolumab
-Ipilimumab
-MK3754

5.   Lung cancers

-Crizotinib
-Afatinib
-Dacomitinib
-Nivolumab
- Selumetinib

5.   Thyroid cancer

-Pazopanib

ANTI-MEK ARE BETTER ANTI-VEGF

Based on what we know now, it is easy to see that in those diseases where Avastin has failed FDA approval, Anti-MEK will do better.  MEK is down stream and MEK is involved in much more, including VEGF expression.  MEK is part of the MEK/MAPK pathways, it is the door to Mesenchymal transformation (that is it the door to epithelial-mesenchymal transition), and therefore to angiogenesis, and to metastatic spread.
Anti-MEK also removes the negative inhibitory effect of the PTEN driven forces of the PI3K/MTOR pathways.

PTEN inhibits insulin-stimulated MEK/MAPK activation andcell growth by blocking IRS-1 phosphorylation and IRS-1/Grb-2/Sos complex formation in a breast cancer model

1. (Liang-Ping Weng1 at al.)   The involvement of the Sons of the Sevenless could signify a large implication on the RAS pathway.  And Anti-MEK were used as Medication to be used in lung cancer displaying amplification of the K-RAS 

Watch it now as Cabozantinib, Selumtinib, and Trametinib will rise in anything Avastin has touched.
Metastatic Colon Cancer is the Primary target!

Only the MTOR inhibitors add to these drugs

Inability of Doxorubicin to add to DTIC in Melanoma is due to amplification of these 2 pathways.

Anti-MEK and MTOR combination will do far better in Melanoma and Pancreatic cancers, mark my words.  We just need to brace ourselves to a new set of side effects.

Meet the newly approved RET/MET/VEGFR inhibitorFromExelixis  

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COMETRIQ is indicated for the treatment of patients with progressive, metastatic medullary thyroid cancer (MTC).

COMETRIQ inhibits the activity of tyrosine kinases including RET, MET, and VEGFRs. These receptor tyrosine kinases are involved in both normal cellular function and in pathologic processes such as oncogenesis, metastasis, tumor angiogenesis, and maintenance of the tumor microenvironment.

COMETRIQ demonstrated significant efficacy in a phase 3 trial (N=330) in metastatic MTC patients with radiographically confirmed disease progression.*

• Significantly prolonged progression-free survival (PFS) vs placebo (HR=0.28; 95% CI: 0.19, 0.40; P<0.0001) — Median PFS was 11.2 months with COMETRIQ vs 4.0 months with placebo • Objective response rate (ORR) was 27% with COMETRIQ vs 0% with placebo (P<0.0001) — Median duration of tumor response was 14.7 months (95% CI: 11.1, 19.3) • Adverse reactions occurring in ≥25% of patients treated with COMETRIQ and more frequently than with placebo (≥5% between-arm difference) in order of decreasing frequency were: diarrhea, stomatitis, palmar-plantar erythrodysesthesia syndrome, decreased weight, decreased appetite, nausea, fatigue, oral pain, hair color changes, dysgeusia, hypertension, abdominal pain, and constipation; the most common laboratory abnormalities (>25%) were increased AST, increased ALT, lymphopenia, increased alkaline phosphatase, hypocalcemia, neutropenia, thrombocytopenia, hypophosphatemia, and hyperbilirubinemia.

*	Results of the international, multicenter, randomized, double-blind EXAM study in patients (N=330) with progressive, metastatic MTC. Primary endpoint: PFS; secondary endpoints: ORR and overall survival (OS). OS data are not yet mature.