Post on 20-Dec-2018
©2015 Laboratory Corporation of America® Holdings. All rights reserved. onc-488-v5-1215
L11353-1215-5
www.integratedoncology.com
Specimen Requirement Options
Unstained slides 5-μm sections on positively-charged glass slides,
1 section per slide. A total of 5 unstained slides per patient is required (sections should contain ≥ 10 mm2 invasive tumor).
Freshly cut sections, stored at 4˚C, and sent within 1 week.
OR
1 paraffin-embedded tissue block (requires formalin-fixed tissue)
If multiple blocks are available, select the tissue block with the highest amount of viable invasive tumor—submit only 1 block.
Note: Invasive carcinoma of the breast is required;
cases with in situ disease only (e.g., DCIS or LCIS) are not acceptable.
Fine needle aspiration (FNA) specimens are not acceptable.
Excisional biopsy specimens are preferred; large core biopsies are also acceptable.
AIDS IN IDENTIFYING CANDIDATES FOR HER2-TARGETED THERAPY
Reimbursement Assistance
Gateway Services can assist your office and your patients with obtaining coverage and reimbursement for HERmark. Gateway makes reimbursement assistance as easy as 1-2-3:
Call Gateway at 1-877-436-6243 prior to ordering a HERmark assay. The appropriate application forms will be sent to you via fax or e-mail.
Complete the application forms and return them to Gateway via fax, 1-888-369-0023.
Receive notification from Gateway of patient eligibility, typically within 24 to 48 hours.
In the event that verification/coverage cannot be established, Gateway can assist with the patient’s case and/or research alternative coverage.
1
2
3
References 1. Shi, Y, Huang, W, Tan, Y, et al. A Novel Proximity Assay for the Detection of Proteins and Protein Complexes: Quantitation of HER1 and HER2 Total Protein
Expression and Homodimerization in Formalin-fixed, Paraffin-Embedded Cell Lines and Breast Cancer Tissue. Diagn Mol Pathol 2009; 18(1):11-21. 2. Larson, JS, Goodman, LJ, Tan, Y, et al., Analytical Validation of a Highly Quantitative, Sensitive, Accurate, and Reproducible Assay (HERmark®) for the
Measurement of HER2 Total Protein and HER2 Homodimers in FFPE Breast Cancer Tumor Specimens. Patholog Res Int. 2010; 2010: 814176. 3. Paik, S et al., Real-World Performance of HER2 Testing—National Surgical Adjuvant Breast and Bowel Project Experience. J Natl Cancer Inst 2002; 94:852-4. 4. Denkert, C et al., HER2 and ESR1 mRNA expression levels and response to neoadjuvant trastuzumab plus chemotherapy in patients with primary breast
cancer. Breast Cancer Research 2013; 15:R11. 5. Yardley, DA et al., Quantitative measurement of HER2 expression in breast cancers: comparison with “real-world” routine HER2 testing in a multicenter
Collaborative Biomarker Study and correlation with overall survival. Breast Cancer Research 2015; 17:41. 6. Lipton, A, Köstler, W, Leitzel, K, et al., Quantitative HER2 protein levels predict outcome in fluorescence in situ hybridization-positive patients with metastatic
breast cancer treated with trastuzumab. Cancer 2010;116:(22): 5168–5178. 7. Scaltriti, M et al., High HER2 Expression Correlates with Response to the Combination of Lapatinib and Trastuzumab. Clin Cancer Res 2015; 2193):569-76. 8. Scaltriti, M et al., High HER2 Expression Correlates with Response to Trastuzumab and the Combination of Trastuzumab and Lapatinib in the NeoALTTO Phase
III Trial. Cancer Res 2013; 73(24 Suppl):Abstract nr P1-08-42. 9. Duchnowska, R, Biernat, W, Szostakiewicz, B, et al., Correlation Between Quantitative HER-2 Protein Expression and Risk for Brain Metastases in HER-2+
Advanced Breast Cancer Patients Receiving Trastuzumab-Containing Therapy. The Oncologist 2012; 17(1):26-35.10. Joensuu, H, Weidler, J, Lie, Y, et al., Quantitative measurements of HER2 expression and HER2 homodimers using a novel proximity based assay: comparison
with HER2 status by immunohistochemistry and chromogenic in situ hybridization in the FinHer study. San Antonio Breast Cancer Symposium, 2008. Abstract #2071.
11. Huang, W, Reinholz, M, Weidler J, et al., Comparison of central HER2 testing with quantitative total HER2 expression and HER2 homodimer measurements using a novel proximity based assay. Am J Clin Pathol 2010;134:303-311.
12. Duchnowska, R, Szostakiewicz, B, Jankowski, T, et al., Correlation between quantitative HER2 protein level and the risk of brain metastasis (BM) in metastatic breast cancer (MBC) patients (pts) treated with trastuzumab-containing therapy. ASCO Annual Meeting 2010. J Clin Oncol 28:15s, 2010 (suppl; abstr 1030).
13. Wolff, AC, Hammond, ME, Schwartz, JN, et al., American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer. J Clin Oncol 2006; 25:118-145.
HERmark Assay Methodology1
The HERmark assay specifically quantifies the full range of HER2 protein expression (H2T) levels in FFPE breast cancer tumor samples.
The VeraTag® methodology uses two primary HER2-specific monoclonal antibodies and proximity-based conjugated fluorescent “VeraTag reporters” that are quantified using capillary electrophoresis.
The amount of released “VeraTag reporters” is proportional to the amount of HER2 protein in the invasive tumor sample.
HERmark® breast cancer assay based on VeraTag® technology
� Direct, quantitative measure of the drug target, HER2 protein
FISH, CISH, SISH, and microarrays are indirect assays of protein expression
Dual antibody format enhances specificity, minimizes background, and results in greater signal/noise ratio
2
HERmark®breastcancerassaybasedonVeraTag™technology
Direct, quantitative measure of the drug target, HER2 protein – FISH, CISH, SISH, and microarrays are
indirect assays of protein expression Dual antibody format
enhances specificity, minimizes background, and results in greater signal/noise ratio
Novel proximity-
based method
HERmark is based on our proprietary VeraTag® technology that precisely quantifies HER2 proteins and protein complexes in formalin-fixed, paraffin-embedded (FFPE) tissue specimens.1
Produces direct quantitative measurement of HER2 protein, the target of current anti-HER2 drug therapies.2
Provides a continuous, rather than semiquantitative, measurement of HER2 total protein over a 3-log dynamic range.2
Demonstrates a 7-to-10 fold improvement in sensitivity over IHC, with detection of HER2 levels down to ~2,500 receptors per cell.2
THE HERMARK® BREAST CANCER ASSAY
Patients with HER2 FISH-positive (HER2/CEP17 ratio ≥ 2.2) samples that were reclassified by HERmark as HER2-low (H2T low) had similar TTP as patients with FISH-negative results (3.7 months and 4.5 months, respectively) (HR, 1.0; p=0.99).
Perc
ent P
rogr
essi
on F
ree
Time (Months)
HERmark HER2 Total high, FISH(+): Median TTP = 11.3 months
HERmark HER2 Total low, FISH(+): Median TTP = 3.7 months
HERmark HER2 Total low, FISH(–): Median TTP = 4.5 months
0 5 10 15 20 25 30 35 40 45 50
TIME TO PROGRESSION (TTP)
60
50
40
30
20
10
0
70
80
90
100
Log 10
HER
2 To
tal
EXAMINATION OF HERMARK/FISH DISCORDANCE
CONCORDANT POSITIVEFISH(+), HER2 Total high
2.5
2.0
1.5
1.0
0.5
0.0Negative Positive
FISH
CONCORDANT NEGATIVEFISH(–), HER2 Total low
DISCORDANTFISH(+), HER2 Total low
H2T CUTOFF
Hazard Ratio (HR) compared to:• HERmark HER2 Total low, FISH(+) = 0.43, P = 0.01• HERmark HER2 Total low, FISH(–) = 0.42, P < 0.001
LOG(H2T) = 1.14
Better Correlation with Clinical Outcomes on Trastuzumab6
Our HERmark clinical study showed HERmark outperformed FISH as a predictor of time to progression (TTP) in patients with metastatic breast cancer treated with trastuzumab (n=102).
Clinical Significance of HERmark
HERmark Provides Accurate HER2 Assessment and Prognostic Value Accurate assessment of HER2 status in breast cancer is critical in identifying patients who may benefit from HER2-targeted therapy. Studies have shown that there still is a relatively high discordance level (18-27%) between central and local HER2 testing.3,4
Representing “real-world” HER2 testing, a recent retrospective, multicenter Collaborative Biomarker Study (CBS) of breast cancer patients (not treated with trastuzumab) showed that the HERmark assay offers accurate quantification of HER2 protein expression that correlated best with central laboratory HER2 IHC re-testing, and less so with local laboratory HER2 IHC and FISH results:5
� HERmark reclassified 15% of local HER2 status negative results as HERmark positives.
HERmark offers a more accurate assessment of HER2 status and may change therapy selection in approximately 20% of patients.
� HERmark has shown to be a better prognostic factor in overall survival in patients for whom HER2 test results were discordant between HERmark and routine HER2 testing.
� The difference in overall survival with the discordant groups did not appear to be due to clinicopathologic factors but more likely due to local HER2 misclassifications.
HERmark Provides Predictive Value HERmark measurements were performed in tumors of patients (n=324) enrolled in the NeoALTTO trial. The NeoALTTO trial evaluated neoadjuvant treatment of lapatinib with trastuzumab vs. either treatment alone for HER2-positive early stage breast cancer. The results of this study include:
Addition of lapatinib to tastuzumab
HERmark-negative Eq. HERmark-positive
Large benefit
Reduced benefit
HER2 levels (all patients)
Pre
dic
ted
pro
ba
bili
ty o
f pC
R
HERmark results were predictive of pathologic complete response (pCR) when patients received trastuzumab or trastuzumab in combination with lapatinib.7
HERmark positive patients had better outcomes and achieved a pCR rate of 39% vs. 11% for HERmark negative (plus equivocal).8
Higher HERmark values achieved better outcomes in the combination arm (lapatinib and trastuzumab) compared to trastuzumab alone.7
Higher HERmark value=increased benefit from addition of lapatinib to trastuzumab
Lower HERmark (but still HER2 positive by IHC/FISH)=reduced benefit from combination treatment
Figure A. HER2 status as stratified by local HER2 status and HERmark levels. HERmark may offer a more accurate assessment of HER2 status when compared to local HER2 measurements, and may change therapy selection in approximately 20% of patients (A. and B.).
Figure B. Kaplan-Meier overall survival analyses for corresponding HERmark concordant and discordant groups. HERmark High (A. Discordant High) and HERmark Low (B. Discordant Low) had similar overall survival curves compared to concordant HERmark/local HER2 positive and concordant HERmark/local HER2 negative, respectively.
Adapted from Yardley et al., Breast Cancer Research 2015; 17:415
A.DiscordantHigh9%
10% B.DiscordantLow
ConcordantNega�ve
B.DiscordantLow
ConcordantPosi�veA.DiscordantHigh
Local HER2
negative
Local HER2
positive
Qu
an
tita
tive
H2T
Le
vels A.DiscordantHigh
9%
10% B.DiscordantLow
ConcordantNega�ve
B.DiscordantLow
ConcordantPosi�veA.DiscordantHigh
Time Since Diagnosis (months)
Ove
rall
Surv
iva
l (%
)
A B
Better Correlation with Time to Brain Metastasis9
HERmark® HER2 protein levels correlated with risk of brain metastases in HER2-positive metastatic breast cancer patients receiving trastuzumab therapy.
Time to brain metastases by A.) HERmark (H2T) median cutoff or B.) FISH/CEP17 ratio median cutoff within the HER2 FISH-positive group of patients
A B
HR, 2.4; p=0.005 HR, 1.3; p=0.4
*Note: Concordance values exclude equivocal results13
HERmark results are reported as Patient HER2 Status (positive, negative, or equivocal) as well as the patient’s precise quantitative HER2 level. The HER2 level is compared to a database with established HERmark reference ranges (1,090 breast cancer patient samples previously defined as HER2-positive or negative according to central reference lab IHC and FISH/CISH).
Comparison with Other HER2 Testing Methods
In validation studies involving more than 1,000 clinical tumor samples, HERmark demonstrated a high level of concordance* with other HER2 testing methods performed in central reference laboratories.
Central IHC10,11 n=808
Central FISH12 n=116
Central IHC and CISH10 n=218
HERmark Assay 96-98% 93% 97%
When to Use HERmark
HERmark offers an alternative HER2 testing method in order to identify candidates for HER2-targeted therapy. Consider HERmark:
When a fully quantitative and validated HER2 protein measurement is desired.
When HER2 status is inconclusive:
Cases with discordant HER2 testing results in IHC and/or FISH (CISH)
Cases with HER2 status “equivocal” by IHC and/or FISH (CISH)
Cases that demonstrate significant heterogeneity in the expression of HER2 protein or gene amplification status of HER2
In cases with HER2 status “negative” by IHC and/or ISH (FISH/CISH), but the patient’s clinical picture (by physician’s assessment and experience) suggests an aggressive (possibly HER2-positive) disease.
HERmark is based on our proprietary VeraTag® technology that precisely quantifies HER2 proteins and protein complexes in formalin-fixed, paraffin-embedded (FFPE) tissue specimens.1
Produces direct quantitative measurement of HER2 protein, the target of current anti-HER2 drug therapies.2
Provides a continuous, rather than semiquantitative, measurement of HER2 total protein over a 3-log dynamic range.2
Demonstrates a 7-to-10 fold improvement in sensitivity over IHC, with detection of HER2 levels down to ~2,500 receptors per cell.2
THE HERMARK® BREAST CANCER ASSAY
Patients with HER2 FISH-positive (HER2/CEP17 ratio ≥ 2.2) samples that were reclassified by HERmark as HER2-low (H2T low) had similar TTP as patients with FISH-negative results (3.7 months and 4.5 months, respectively) (HR, 1.0; p=0.99).
Perc
ent P
rogr
essi
on F
ree
Time (Months)
HERmark HER2 Total high, FISH(+): Median TTP = 11.3 months
HERmark HER2 Total low, FISH(+): Median TTP = 3.7 months
HERmark HER2 Total low, FISH(–): Median TTP = 4.5 months
0 5 10 15 20 25 30 35 40 45 50
TIME TO PROGRESSION (TTP)
60
50
40
30
20
10
0
70
80
90
100
Log 10
HER
2 To
tal
EXAMINATION OF HERMARK/FISH DISCORDANCE
CONCORDANT POSITIVEFISH(+), HER2 Total high
2.5
2.0
1.5
1.0
0.5
0.0Negative Positive
FISH
CONCORDANT NEGATIVEFISH(–), HER2 Total low
DISCORDANTFISH(+), HER2 Total low
H2T CUTOFF
Hazard Ratio (HR) compared to:• HERmark HER2 Total low, FISH(+) = 0.43, P = 0.01• HERmark HER2 Total low, FISH(–) = 0.42, P < 0.001
LOG(H2T) = 1.14
Better Correlation with Clinical Outcomes on Trastuzumab6
Our HERmark clinical study showed HERmark outperformed FISH as a predictor of time to progression (TTP) in patients with metastatic breast cancer treated with trastuzumab (n=102).
Clinical Significance of HERmark
HERmark Provides Accurate HER2 Assessment and Prognostic Value Accurate assessment of HER2 status in breast cancer is critical in identifying patients who may benefit from HER2-targeted therapy. Studies have shown that there still is a relatively high discordance level (18-27%) between central and local HER2 testing.3,4
Representing “real-world” HER2 testing, a recent retrospective, multicenter Collaborative Biomarker Study (CBS) of breast cancer patients (not treated with trastuzumab) showed that the HERmark assay offers accurate quantification of HER2 protein expression that correlated best with central laboratory HER2 IHC re-testing, and less so with local laboratory HER2 IHC and FISH results:5
� HERmark reclassified 15% of local HER2 status negative results as HERmark positives.
HERmark offers a more accurate assessment of HER2 status and may change therapy selection in approximately 20% of patients.
� HERmark has shown to be a better prognostic factor in overall survival in patients for whom HER2 test results were discordant between HERmark and routine HER2 testing.
� The difference in overall survival with the discordant groups did not appear to be due to clinicopathologic factors but more likely due to local HER2 misclassifications.
HERmark Provides Predictive Value HERmark measurements were performed in tumors of patients (n=324) enrolled in the NeoALTTO trial. The NeoALTTO trial evaluated neoadjuvant treatment of lapatinib with trastuzumab vs. either treatment alone for HER2-positive early stage breast cancer. The results of this study include:
Addition of lapatinib to tastuzumab
HERmark-negative Eq. HERmark-positive
Large benefit
Reduced benefit
HER2 levels (all patients)
Pre
dic
ted
pro
ba
bili
ty o
f pC
R
HERmark results were predictive of pathologic complete response (pCR) when patients received trastuzumab or trastuzumab in combination with lapatinib.7
HERmark positive patients had better outcomes and achieved a pCR rate of 39% vs. 11% for HERmark negative (plus equivocal).8
Higher HERmark values achieved better outcomes in the combination arm (lapatinib and trastuzumab) compared to trastuzumab alone.7
Higher HERmark value=increased benefit from addition of lapatinib to trastuzumab
Lower HERmark (but still HER2 positive by IHC/FISH)=reduced benefit from combination treatment
Figure A. HER2 status as stratified by local HER2 status and HERmark levels. HERmark may offer a more accurate assessment of HER2 status when compared to local HER2 measurements, and may change therapy selection in approximately 20% of patients (A. and B.).
Figure B. Kaplan-Meier overall survival analyses for corresponding HERmark concordant and discordant groups. HERmark High (A. Discordant High) and HERmark Low (B. Discordant Low) had similar overall survival curves compared to concordant HERmark/local HER2 positive and concordant HERmark/local HER2 negative, respectively.
Adapted from Yardley et al., Breast Cancer Research 2015; 17:415
A.DiscordantHigh9%
10% B.DiscordantLow
ConcordantNega�ve
B.DiscordantLow
ConcordantPosi�veA.DiscordantHigh
Local HER2
negative
Local HER2
positive
Qu
an
tita
tive
H2T
Le
vels A.DiscordantHigh
9%
10% B.DiscordantLow
ConcordantNega�ve
B.DiscordantLow
ConcordantPosi�veA.DiscordantHigh
Time Since Diagnosis (months)
Ove
rall
Surv
iva
l (%
)
A B
Better Correlation with Time to Brain Metastasis9
HERmark® HER2 protein levels correlated with risk of brain metastases in HER2-positive metastatic breast cancer patients receiving trastuzumab therapy.
Time to brain metastases by A.) HERmark (H2T) median cutoff or B.) FISH/CEP17 ratio median cutoff within the HER2 FISH-positive group of patients
A B
HR, 2.4; p=0.005 HR, 1.3; p=0.4
*Note: Concordance values exclude equivocal results13
HERmark results are reported as Patient HER2 Status (positive, negative, or equivocal) as well as the patient’s precise quantitative HER2 level. The HER2 level is compared to a database with established HERmark reference ranges (1,090 breast cancer patient samples previously defined as HER2-positive or negative according to central reference lab IHC and FISH/CISH).
Comparison with Other HER2 Testing Methods
In validation studies involving more than 1,000 clinical tumor samples, HERmark demonstrated a high level of concordance* with other HER2 testing methods performed in central reference laboratories.
Central IHC10,11 n=808
Central FISH12 n=116
Central IHC and CISH10 n=218
HERmark Assay 96-98% 93% 97%
When to Use HERmark
HERmark offers an alternative HER2 testing method in order to identify candidates for HER2-targeted therapy. Consider HERmark:
When a fully quantitative and validated HER2 protein measurement is desired.
When HER2 status is inconclusive:
Cases with discordant HER2 testing results in IHC and/or FISH (CISH)
Cases with HER2 status “equivocal” by IHC and/or FISH (CISH)
Cases that demonstrate significant heterogeneity in the expression of HER2 protein or gene amplification status of HER2
In cases with HER2 status “negative” by IHC and/or ISH (FISH/CISH), but the patient’s clinical picture (by physician’s assessment and experience) suggests an aggressive (possibly HER2-positive) disease.
HERmark is based on our proprietary VeraTag® technology that precisely quantifies HER2 proteins and protein complexes in formalin-fixed, paraffin-embedded (FFPE) tissue specimens.1
Produces direct quantitative measurement of HER2 protein, the target of current anti-HER2 drug therapies.2
Provides a continuous, rather than semiquantitative, measurement of HER2 total protein over a 3-log dynamic range.2
Demonstrates a 7-to-10 fold improvement in sensitivity over IHC, with detection of HER2 levels down to ~2,500 receptors per cell.2
THE HERMARK® BREAST CANCER ASSAY
Patients with HER2 FISH-positive (HER2/CEP17 ratio ≥ 2.2) samples that were reclassified by HERmark as HER2-low (H2T low) had similar TTP as patients with FISH-negative results (3.7 months and 4.5 months, respectively) (HR, 1.0; p=0.99).
Perc
ent P
rogr
essi
on F
ree
Time (Months)
HERmark HER2 Total high, FISH(+): Median TTP = 11.3 months
HERmark HER2 Total low, FISH(+): Median TTP = 3.7 months
HERmark HER2 Total low, FISH(–): Median TTP = 4.5 months
0 5 10 15 20 25 30 35 40 45 50
TIME TO PROGRESSION (TTP)
60
50
40
30
20
10
0
70
80
90
100
Log 10
HER
2 To
tal
EXAMINATION OF HERMARK/FISH DISCORDANCE
CONCORDANT POSITIVEFISH(+), HER2 Total high
2.5
2.0
1.5
1.0
0.5
0.0Negative Positive
FISH
CONCORDANT NEGATIVEFISH(–), HER2 Total low
DISCORDANTFISH(+), HER2 Total low
H2T CUTOFF
Hazard Ratio (HR) compared to:• HERmark HER2 Total low, FISH(+) = 0.43, P = 0.01• HERmark HER2 Total low, FISH(–) = 0.42, P < 0.001
LOG(H2T) = 1.14
Better Correlation with Clinical Outcomes on Trastuzumab6
Our HERmark clinical study showed HERmark outperformed FISH as a predictor of time to progression (TTP) in patients with metastatic breast cancer treated with trastuzumab (n=102).
Clinical Significance of HERmark
HERmark Provides Accurate HER2 Assessment and Prognostic Value Accurate assessment of HER2 status in breast cancer is critical in identifying patients who may benefit from HER2-targeted therapy. Studies have shown that there still is a relatively high discordance level (18-27%) between central and local HER2 testing.3,4
Representing “real-world” HER2 testing, a recent retrospective, multicenter Collaborative Biomarker Study (CBS) of breast cancer patients (not treated with trastuzumab) showed that the HERmark assay offers accurate quantification of HER2 protein expression that correlated best with central laboratory HER2 IHC re-testing, and less so with local laboratory HER2 IHC and FISH results:5
� HERmark reclassified 15% of local HER2 status negative results as HERmark positives.
HERmark offers a more accurate assessment of HER2 status and may change therapy selection in approximately 20% of patients.
� HERmark has shown to be a better prognostic factor in overall survival in patients for whom HER2 test results were discordant between HERmark and routine HER2 testing.
� The difference in overall survival with the discordant groups did not appear to be due to clinicopathologic factors but more likely due to local HER2 misclassifications.
HERmark Provides Predictive Value HERmark measurements were performed in tumors of patients (n=324) enrolled in the NeoALTTO trial. The NeoALTTO trial evaluated neoadjuvant treatment of lapatinib with trastuzumab vs. either treatment alone for HER2-positive early stage breast cancer. The results of this study include:
Addition of lapatinib to tastuzumab
HERmark-negative Eq. HERmark-positive
Large benefit
Reduced benefit
HER2 levels (all patients)
Pre
dic
ted
pro
ba
bili
ty o
f pC
R
HERmark results were predictive of pathologic complete response (pCR) when patients received trastuzumab or trastuzumab in combination with lapatinib.7
HERmark positive patients had better outcomes and achieved a pCR rate of 39% vs. 11% for HERmark negative (plus equivocal).8
Higher HERmark values achieved better outcomes in the combination arm (lapatinib and trastuzumab) compared to trastuzumab alone.7
Higher HERmark value=increased benefit from addition of lapatinib to trastuzumab
Lower HERmark (but still HER2 positive by IHC/FISH)=reduced benefit from combination treatment
Figure A. HER2 status as stratified by local HER2 status and HERmark levels. HERmark may offer a more accurate assessment of HER2 status when compared to local HER2 measurements, and may change therapy selection in approximately 20% of patients (A. and B.).
Figure B. Kaplan-Meier overall survival analyses for corresponding HERmark concordant and discordant groups. HERmark High (A. Discordant High) and HERmark Low (B. Discordant Low) had similar overall survival curves compared to concordant HERmark/local HER2 positive and concordant HERmark/local HER2 negative, respectively.
Adapted from Yardley et al., Breast Cancer Research 2015; 17:415
A.DiscordantHigh9%
10% B.DiscordantLow
ConcordantNega�ve
B.DiscordantLow
ConcordantPosi�veA.DiscordantHigh
Local HER2
negative
Local HER2
positive
Qu
an
tita
tive
H2T
Le
vels A.DiscordantHigh
9%
10% B.DiscordantLow
ConcordantNega�ve
B.DiscordantLow
ConcordantPosi�veA.DiscordantHigh
Time Since Diagnosis (months)
Ove
rall
Surv
iva
l (%
)
A B
Better Correlation with Time to Brain Metastasis9
HERmark® HER2 protein levels correlated with risk of brain metastases in HER2-positive metastatic breast cancer patients receiving trastuzumab therapy.
Time to brain metastases by A.) HERmark (H2T) median cutoff or B.) FISH/CEP17 ratio median cutoff within the HER2 FISH-positive group of patients
A B
HR, 2.4; p=0.005 HR, 1.3; p=0.4
*Note: Concordance values exclude equivocal results13
HERmark results are reported as Patient HER2 Status (positive, negative, or equivocal) as well as the patient’s precise quantitative HER2 level. The HER2 level is compared to a database with established HERmark reference ranges (1,090 breast cancer patient samples previously defined as HER2-positive or negative according to central reference lab IHC and FISH/CISH).
Comparison with Other HER2 Testing Methods
In validation studies involving more than 1,000 clinical tumor samples, HERmark demonstrated a high level of concordance* with other HER2 testing methods performed in central reference laboratories.
Central IHC10,11 n=808
Central FISH12 n=116
Central IHC and CISH10 n=218
HERmark Assay 96-98% 93% 97%
When to Use HERmark
HERmark offers an alternative HER2 testing method in order to identify candidates for HER2-targeted therapy. Consider HERmark:
When a fully quantitative and validated HER2 protein measurement is desired.
When HER2 status is inconclusive:
Cases with discordant HER2 testing results in IHC and/or FISH (CISH)
Cases with HER2 status “equivocal” by IHC and/or FISH (CISH)
Cases that demonstrate significant heterogeneity in the expression of HER2 protein or gene amplification status of HER2
In cases with HER2 status “negative” by IHC and/or ISH (FISH/CISH), but the patient’s clinical picture (by physician’s assessment and experience) suggests an aggressive (possibly HER2-positive) disease.
©2015 Laboratory Corporation of America® Holdings. All rights reserved. onc-488-v5-1215
L11353-1215-5
www.integratedoncology.com
Specimen Requirement Options
Unstained slides 5-μm sections on positively-charged glass slides,
1 section per slide. A total of 5 unstained slides per patient is required (sections should contain ≥ 10 mm2 invasive tumor).
Freshly cut sections, stored at 4˚C, and sent within 1 week.
OR
1 paraffin-embedded tissue block (requires formalin-fixed tissue)
If multiple blocks are available, select the tissue block with the highest amount of viable invasive tumor—submit only 1 block.
Note: Invasive carcinoma of the breast is required;
cases with in situ disease only (e.g., DCIS or LCIS) are not acceptable.
Fine needle aspiration (FNA) specimens are not acceptable.
Excisional biopsy specimens are preferred; large core biopsies are also acceptable.
AIDS IN IDENTIFYING CANDIDATES FOR HER2-TARGETED THERAPY
Reimbursement Assistance
Gateway Services can assist your office and your patients with obtaining coverage and reimbursement for HERmark. Gateway makes reimbursement assistance as easy as 1-2-3:
Call Gateway at 1-877-436-6243 prior to ordering a HERmark assay. The appropriate application forms will be sent to you via fax or e-mail.
Complete the application forms and return them to Gateway via fax, 1-888-369-0023.
Receive notification from Gateway of patient eligibility, typically within 24 to 48 hours.
In the event that verification/coverage cannot be established, Gateway can assist with the patient’s case and/or research alternative coverage.
1
2
3
References 1. Shi, Y, Huang, W, Tan, Y, et al. A Novel Proximity Assay for the Detection of Proteins and Protein Complexes: Quantitation of HER1 and HER2 Total Protein
Expression and Homodimerization in Formalin-fixed, Paraffin-Embedded Cell Lines and Breast Cancer Tissue. Diagn Mol Pathol 2009; 18(1):11-21. 2. Larson, JS, Goodman, LJ, Tan, Y, et al., Analytical Validation of a Highly Quantitative, Sensitive, Accurate, and Reproducible Assay (HERmark®) for the
Measurement of HER2 Total Protein and HER2 Homodimers in FFPE Breast Cancer Tumor Specimens. Patholog Res Int. 2010; 2010: 814176. 3. Paik, S et al., Real-World Performance of HER2 Testing—National Surgical Adjuvant Breast and Bowel Project Experience. J Natl Cancer Inst 2002; 94:852-4. 4. Denkert, C et al., HER2 and ESR1 mRNA expression levels and response to neoadjuvant trastuzumab plus chemotherapy in patients with primary breast
cancer. Breast Cancer Research 2013; 15:R11. 5. Yardley, DA et al., Quantitative measurement of HER2 expression in breast cancers: comparison with “real-world” routine HER2 testing in a multicenter
Collaborative Biomarker Study and correlation with overall survival. Breast Cancer Research 2015; 17:41. 6. Lipton, A, Köstler, W, Leitzel, K, et al., Quantitative HER2 protein levels predict outcome in fluorescence in situ hybridization-positive patients with metastatic
breast cancer treated with trastuzumab. Cancer 2010;116:(22): 5168–5178. 7. Scaltriti, M et al., High HER2 Expression Correlates with Response to the Combination of Lapatinib and Trastuzumab. Clin Cancer Res 2015; 2193):569-76. 8. Scaltriti, M et al., High HER2 Expression Correlates with Response to Trastuzumab and the Combination of Trastuzumab and Lapatinib in the NeoALTTO Phase
III Trial. Cancer Res 2013; 73(24 Suppl):Abstract nr P1-08-42. 9. Duchnowska, R, Biernat, W, Szostakiewicz, B, et al., Correlation Between Quantitative HER-2 Protein Expression and Risk for Brain Metastases in HER-2+
Advanced Breast Cancer Patients Receiving Trastuzumab-Containing Therapy. The Oncologist 2012; 17(1):26-35.10. Joensuu, H, Weidler, J, Lie, Y, et al., Quantitative measurements of HER2 expression and HER2 homodimers using a novel proximity based assay: comparison
with HER2 status by immunohistochemistry and chromogenic in situ hybridization in the FinHer study. San Antonio Breast Cancer Symposium, 2008. Abstract #2071.
11. Huang, W, Reinholz, M, Weidler J, et al., Comparison of central HER2 testing with quantitative total HER2 expression and HER2 homodimer measurements using a novel proximity based assay. Am J Clin Pathol 2010;134:303-311.
12. Duchnowska, R, Szostakiewicz, B, Jankowski, T, et al., Correlation between quantitative HER2 protein level and the risk of brain metastasis (BM) in metastatic breast cancer (MBC) patients (pts) treated with trastuzumab-containing therapy. ASCO Annual Meeting 2010. J Clin Oncol 28:15s, 2010 (suppl; abstr 1030).
13. Wolff, AC, Hammond, ME, Schwartz, JN, et al., American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer. J Clin Oncol 2006; 25:118-145.
HERmark Assay Methodology1
The HERmark assay specifically quantifies the full range of HER2 protein expression (H2T) levels in FFPE breast cancer tumor samples.
The VeraTag® methodology uses two primary HER2-specific monoclonal antibodies and proximity-based conjugated fluorescent “VeraTag reporters” that are quantified using capillary electrophoresis.
The amount of released “VeraTag reporters” is proportional to the amount of HER2 protein in the invasive tumor sample.
HERmark® breast cancer assay based on VeraTag® technology
� Direct, quantitative measure of the drug target, HER2 protein
FISH, CISH, SISH, and microarrays are indirect assays of protein expression
Dual antibody format enhances specificity, minimizes background, and results in greater signal/noise ratio
2
HERmark®breastcancerassaybasedonVeraTag™technology
Direct, quantitative measure of the drug target, HER2 protein – FISH, CISH, SISH, and microarrays are
indirect assays of protein expression Dual antibody format
enhances specificity, minimizes background, and results in greater signal/noise ratio
Novel proximity-
based method
©2015 Laboratory Corporation of America® Holdings. All rights reserved. onc-488-v5-1215
L11353-1215-5
www.integratedoncology.com
Specimen Requirement Options
Unstained slides 5-μm sections on positively-charged glass slides,
1 section per slide. A total of 5 unstained slides per patient is required (sections should contain ≥ 10 mm2 invasive tumor).
Freshly cut sections, stored at 4˚C, and sent within 1 week.
OR
1 paraffin-embedded tissue block (requires formalin-fixed tissue)
If multiple blocks are available, select the tissue block with the highest amount of viable invasive tumor—submit only 1 block.
Note: Invasive carcinoma of the breast is required;
cases with in situ disease only (e.g., DCIS or LCIS) are not acceptable.
Fine needle aspiration (FNA) specimens are not acceptable.
Excisional biopsy specimens are preferred; large core biopsies are also acceptable.
AIDS IN IDENTIFYING CANDIDATES FOR HER2-TARGETED THERAPY
Reimbursement Assistance
Gateway Services can assist your office and your patients with obtaining coverage and reimbursement for HERmark. Gateway makes reimbursement assistance as easy as 1-2-3:
Call Gateway at 1-877-436-6243 prior to ordering a HERmark assay. The appropriate application forms will be sent to you via fax or e-mail.
Complete the application forms and return them to Gateway via fax, 1-888-369-0023.
Receive notification from Gateway of patient eligibility, typically within 24 to 48 hours.
In the event that verification/coverage cannot be established, Gateway can assist with the patient’s case and/or research alternative coverage.
1
2
3
References 1. Shi, Y, Huang, W, Tan, Y, et al. A Novel Proximity Assay for the Detection of Proteins and Protein Complexes: Quantitation of HER1 and HER2 Total Protein
Expression and Homodimerization in Formalin-fixed, Paraffin-Embedded Cell Lines and Breast Cancer Tissue. Diagn Mol Pathol 2009; 18(1):11-21. 2. Larson, JS, Goodman, LJ, Tan, Y, et al., Analytical Validation of a Highly Quantitative, Sensitive, Accurate, and Reproducible Assay (HERmark®) for the
Measurement of HER2 Total Protein and HER2 Homodimers in FFPE Breast Cancer Tumor Specimens. Patholog Res Int. 2010; 2010: 814176. 3. Paik, S et al., Real-World Performance of HER2 Testing—National Surgical Adjuvant Breast and Bowel Project Experience. J Natl Cancer Inst 2002; 94:852-4. 4. Denkert, C et al., HER2 and ESR1 mRNA expression levels and response to neoadjuvant trastuzumab plus chemotherapy in patients with primary breast
cancer. Breast Cancer Research 2013; 15:R11. 5. Yardley, DA et al., Quantitative measurement of HER2 expression in breast cancers: comparison with “real-world” routine HER2 testing in a multicenter
Collaborative Biomarker Study and correlation with overall survival. Breast Cancer Research 2015; 17:41. 6. Lipton, A, Köstler, W, Leitzel, K, et al., Quantitative HER2 protein levels predict outcome in fluorescence in situ hybridization-positive patients with metastatic
breast cancer treated with trastuzumab. Cancer 2010;116:(22): 5168–5178. 7. Scaltriti, M et al., High HER2 Expression Correlates with Response to the Combination of Lapatinib and Trastuzumab. Clin Cancer Res 2015; 2193):569-76. 8. Scaltriti, M et al., High HER2 Expression Correlates with Response to Trastuzumab and the Combination of Trastuzumab and Lapatinib in the NeoALTTO Phase
III Trial. Cancer Res 2013; 73(24 Suppl):Abstract nr P1-08-42. 9. Duchnowska, R, Biernat, W, Szostakiewicz, B, et al., Correlation Between Quantitative HER-2 Protein Expression and Risk for Brain Metastases in HER-2+
Advanced Breast Cancer Patients Receiving Trastuzumab-Containing Therapy. The Oncologist 2012; 17(1):26-35.10. Joensuu, H, Weidler, J, Lie, Y, et al., Quantitative measurements of HER2 expression and HER2 homodimers using a novel proximity based assay: comparison
with HER2 status by immunohistochemistry and chromogenic in situ hybridization in the FinHer study. San Antonio Breast Cancer Symposium, 2008. Abstract #2071.
11. Huang, W, Reinholz, M, Weidler J, et al., Comparison of central HER2 testing with quantitative total HER2 expression and HER2 homodimer measurements using a novel proximity based assay. Am J Clin Pathol 2010;134:303-311.
12. Duchnowska, R, Szostakiewicz, B, Jankowski, T, et al., Correlation between quantitative HER2 protein level and the risk of brain metastasis (BM) in metastatic breast cancer (MBC) patients (pts) treated with trastuzumab-containing therapy. ASCO Annual Meeting 2010. J Clin Oncol 28:15s, 2010 (suppl; abstr 1030).
13. Wolff, AC, Hammond, ME, Schwartz, JN, et al., American Society of Clinical Oncology/College of American Pathologists Guideline Recommendations for Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer. J Clin Oncol 2006; 25:118-145.
HERmark Assay Methodology1
The HERmark assay specifically quantifies the full range of HER2 protein expression (H2T) levels in FFPE breast cancer tumor samples.
The VeraTag® methodology uses two primary HER2-specific monoclonal antibodies and proximity-based conjugated fluorescent “VeraTag reporters” that are quantified using capillary electrophoresis.
The amount of released “VeraTag reporters” is proportional to the amount of HER2 protein in the invasive tumor sample.
HERmark® breast cancer assay based on VeraTag® technology
� Direct, quantitative measure of the drug target, HER2 protein
FISH, CISH, SISH, and microarrays are indirect assays of protein expression
Dual antibody format enhances specificity, minimizes background, and results in greater signal/noise ratio
2
HERmark®breastcancerassaybasedonVeraTag™technology
Direct, quantitative measure of the drug target, HER2 protein – FISH, CISH, SISH, and microarrays are
indirect assays of protein expression Dual antibody format
enhances specificity, minimizes background, and results in greater signal/noise ratio
Novel proximity-
based method