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The student news site of Bearden High School
Staff picks: Bands we most want to see live
Bark Staff|November 15, 2013
Promo photo
Phoenix is one of the bands we most want to see live.
There are few thrills bigger than seeing your favorite band in concert (ideally, pressed up against the stage, surrounded by sweaty, energetic concertgoers, of course). Some of us have seen a lot of bands play, and some have only seen a few, but we all have that one band whom we'd give an arm and a leg to see. Here are some of the bands on our concert wishlists.
My favorite band in the world is Switchfoot. Switchfoot is a Christian rock band. If you have ever seen the movie A Walk to Remember, then you are probably familiar with their song "Dare You to Move." Switchfoot's music is brutally honest, but at the same time is fun to jam out to in your car with your windows rolled down. I have been listening to Switchfoot's music since the age of 7 and I have yet to see them in concert, which is something that I am determined to do before they discontinue making music forever. [Litza Craig]
If I really had to choose one band to see in concert (and I really hate picking just one), I think I'd pick Phoenix. Phoenix has been one of my favorite bands for many years now, so going to one of their concerts would be a pretty spectacular thing. The hard part would be finding a group of people that actually know who they are and would like going just as much as I'd want to. Luckily I have influenced my little sister well and she might just jam with me. [Taylor A. Johnson]
I've been waiting my entire life just to see Adam Levine in person because I love him so much, so of course the band I want to see in concert is Maroon 5. Not only do I love Adam, but I actually love Maroon 5's music. Personally, I like the good old songs from 2002's Songs About Jane, so if and when I do see Maroon 5, I will look forward to those the most. I've been saving money for years now to be able to buy tickets to their show the next time they come within a 200-mile radius. I'm determined to have front row too, so any donations are welcome. [Katie Matthews]
Let's see here. I've been to Music Midtown, seen Grouplove and Mutemath in the same week, and am fully committed to going to Bonnaroo this year, so I've seen a fair amount of shows. One band that escapes me, though, is Grizzly Bear. I mean, with albums like Veckatimest and Shields, you have to appreciate what Grizzly Bear has got going on. [Ed Dudrick]
I've listened to Fleet Foxes just about every day since I heard of them. Usually I can't pick a favorite band, but right now it's clearly them. Already, listening to their music fills the room with a certain relaxing, woodsy mood, so I can't imagine how amazing they would be in person. [Allie Gruszkiewicz]
In my opinion, the best band to see live has got to be Relient K. They seem like their concerts would be extremely fun and entertaining for those in attendance. Relient K has slowly evolved from a lively punk rock band to a more mature, pop-rock style that has really grown on me rather quickly. They are one of those bands that goes all out during concerts and are sweaty and worn out by the end of the concert. [Graham Benefiel]
Okay, one thing to know about me is that I love to dance; I'm not good at it, but I love to do it anyways, so Edward Sharpe and the Magnetic Zeros is the band that I have to see in concert due mainly to the fact that Alex Ebert is constantly jumping around and getting into his music on stage, which I love. The band is not like these pop artists that have these ridiculous outfits and stage designs to entertain a stadium full of people; it's just honestly loving the music they are making and loving the fact that they are sharing it with people. In Big Easy Express – a documentary about Edward Sharpe and the Magnetic Zeros, Old Crow Medicine Show, and Mumford & Sons touring together on a train – Marcus Mumford said that they were his favorite band to watch live, so I feel validated. [Kelsey Kinzer]
My absolute favorite band is the fantastic, albeit ridiculously named, The Front Bottoms. Their music has had a massive impact on me and seeing them live would probably complete my life. Honestly, there is not a band – currently active or not – I would rather see. [Emily Price]
Having seen only three concerts in my life and two of those concerts being Disney stars (The Cheetah Girls and Hannah Montana), I really want to finally see an actually talented performer. If I could go to any concert, I would want to see Ed Sheeran. First of all his voice and lyrics are amazing, even if some people disagree *cough* JACK *cough*, and second because from the videos I've watched of his concerts, he interacts with his crowd, unlike many performers nowadays. [Hannah McElroy]
I've seen a lot of concerts (a lot), but 2013 has been the best year of my life for seeing live bands. Between being squished in the second row for the Dillinger Escape Plan's manic stage show, catching the Neutral Milk Hotel reunion tour, hanging out with art rappers Milo and Safari Al, and seeing Between the Buried and Me play all of The Parallax II, I've crossed a lot off my concert bucket list. But if any band seems to be close to Dillinger in terms of sheer stage energy, it's Converge. Their ferocious metalcore is some of the most influential (and best) music of the last 20 years, and judging from some of the full-concert videos online, they really know how to shrink a room: you can't get much more intimate at a concert than Jacob Bannon jumping into the crowd and waving a microphone in your face. [Jack H. Evans]
When it comes to boy bands, there is none better than the one and only Big Time Rush. Not only are their songs upbeat and cute, but the people themselves are incredibly attractive. I have asked for concert tickets the past two years for my birthday and have yet to receive them. Maybe one day my dream of seeing Big Time Rush live will become a reality. [Zoey Line]
Senior Committee starting new tradition by hosting first ever BHS Senior Sunset
Yoga Club provides stress relief at no cost for students, staff
Staff picks: Best of 2015/16 at Bearden
Staff Picks: Favorite spring jams
Staff picks: Best photo op locations in East Tennessee
Staff picks: Knoxville's best breakfast spots
Staff picks: Spring break at home
Staff picks: Tips for staying organized
Staff picks: Our favorite classes at Bearden
Staff picks: Most entertaining mobile app


was born 11 February 1949 and registered to vote, giving the address 1200 SW 118 PL in OKLAHOMA CITY, Oklahoma, U.S.A. 73170. MCGUIRE registered as a Republican. MCGUIRE voted in person on 6 November 2012, voted absentee in person on 24 June 2014, voted absentee in person on 4 November 2014, voted absentee in person on 1 March 2016, voted absentee in person on 8 November 2016, voted in person on 14 November 2017, voted in person on 13 February 2018, voted in person on 26 June 2018, voted absentee in person on 28 August 2018 and voted absentee in person on 6 November 2018.


Boise River flows Wednesday were at the lowest levels the area has experienced since March. Still hovering just above the flood stage, there may be hope for a float season.
A warning sign is posted at the Barber Park launch point and likely will be for at least another month and a half, if not through the first weekend in Sept. If that were the case, there would be no float season from Barber Park to Ann Morrison Park all together this year.
"We're at the mercy of a lot of different, unknown factors right now," says Scott Koberg, director of Ada County Parks & Waterways.
The top three factors Koberg references include a river flow range between 700-1,500 cubic-feet-per-second. Currently, the Boise River is at 7,250 CFS.
Once the river comes down, then it's safe for a Boise Fire Department special operations unit to clear debris out of the waterway, which it's anticipated there will be more this year.
Also, the temperature needs to be about an 80 degree average.
Normal year or not, the floater concession at Barber Park in Boise closes on Labor Day.
However, if everything lines up just right, the float season could occur in August.
So, the rafts have recently been inflated and inspected, and managers are out getting a first glimpse at possible water damage. They won't be able to really tell what repairs are in order until the river level comes down.
What's most encouraging, Koberg says, is that the Boise River is now past the flooding peak.
Water managers with the reservoir storage system, the Bureau of Reclamation and the U.S. Army Corps of Engineers will continue to carefully monitor the situation.
"They've still got a lot of work ahead of them to balance the water budget for the year from reservoir storage and recreation up at the lakes, to irrigation delivery to farmers and ranchers and then, hopefully, for recreational users on the river," Koberg says.
Check out Float the Boise River's Facebook page for up-to-date information on a possible opening date.
Even though levels are starting to come down, though, officials say the water is still very dangerous for people and their pets.


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Who asked you?, Terry McMillan
The Resource Who asked you?, Terry McMillan
The item Who asked you?, Terry McMillan represents a specific, individual, material embodiment of a distinct intellectual or artistic creation found in Evansville Vanderburgh Public Library.
McMillan, Terry
"Family ties are tested and transformed in the new novel from #1 New York Times bestselling author of Waiting to Exhale and How Stella Got Her Groove Back With her wise, wry, and poignant novels of families and friendships-Waiting to Exhale, Getting to Happy, and A Day Late and a Dollar Short among them-Terry McMillan has touched millions of readers. Now, in her eighth novel, McMillan gives exuberant voice to characters who reveal how we live now-at least as lived in a racially diverse Los Angeles neighborhood. Kaleidoscopic, fast-paced, and filled with McMillan's inimitable humor, Who Asked You? opens as Trinetta leaves her two young sons with her mother, Betty Jean, and promptly disappears. BJ, a trademark McMillan heroine, already has her hands full dealing with her other adult children, two opinionated sisters, an ill husband, and her own postponed dreams-all while holding down a job as a hotel maid. Her son Dexter is about to be paroled from prison; Quentin, the family success, can't be bothered to lend a hand; and taking care of two lively grandsons is the last thing BJ thinks she needs. The drama unfolds through the perspectives of a rotating cast of characters, pitch-perfect, each playing a part, and full of surprises. Who Asked You? casts an intimate look at the burdens and blessings of family and speaks to trusting your own judgment even when others don't agree. McMillan's signature voice and unforgettable characters bring universal issues to brilliant, vivid life"--
"With her wise, wry, and poignant novels of families and friendships--Waiting to Exhale, Getting to Happy, and A Day Late and a Dollar Short among them--Terry McMillan has touched millions of readers. Now, in her eighth novel, McMillan gives exuberant voice to characters who reveal how we live now--at least as lived in a racially diverse Los Angeles neighborhood. Who Asked You? opens as Trinetta leaves her two young sons with her mother, Betty Jean, and promptly disappears. BJ, a trademark McMillan heroine, already has her hands full dealing with her other adult children, two opinionated sisters, an ill husband, and her own postponed dreams--all while holding down a job as a hotel maid. Her son Dexter is about to be paroled from prison; Quentin, the family success, can't be bothered to lend a hand; and taking care of two lively grandsons is the last thing BJ thinks she needs. The drama unfolds through the perspectives of a rotating cast of characters, pitch-perfect, each playing a part, and full of surprises"--
New York, New York, USA, Viking, 2013
Who asked you?
Dysfunctional families -- Fiction
FICTION / African American / Contemporary Women
African American women -- Fiction
FICTION / Contemporary Women
PS3563.C3868

 Data from Who asked you?, Terry McMillan - Evansville Vanderburgh Public Library

Data Citation of the Item Who asked you?, Terry McMillan

redpajama_set_name: RedPajamaCommonCrawl


"I am enough of an artist to draw freely upon my imagination. Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world." "What Life Means to Einstein: An Interview by George Sylvester Viereck," for the October 26, 1929 issue of The Saturday Evening Post.


Sorry only a facebook link , cant find it on Youtube.
He makes it look deceptively easy. It takes real guts and faith (and sharp edges), to allow your skis to get so far away from your hips....it's a great example of "Long Leg / Short Leg".
Like all masters of their craft , looks effortless.
Indeed and a little hypnotic.
The most dangerous development in Ski Technology.
More Piste accidents (some fatal) have been caused by Carving.
@stanton, it may have escaped your attention that he's a racer, not an ordinary piste skier, you blithering moron.
Now there's a good word... "blithering" ...and perfectly used.
he not just "a racer" - He's Ted Ligety - two time olympic champion, 5x world champion with over 50 podiums in world cup events. The man can ski.
And there was I tuning into this thread thinking I would find a nice big slab of roast beef or pork.
Pfft... Ye call THAT carving? Ted Ligety? Ted Skid-turny more like!
FFwd to 1:20 to avoid usual snow video nonsense.
As much as it feels like eating someone else's vomit, I agree with Stanton to a point on this one, I do like carving but I recognise that there are significantly higher risks of collision with the technique.
Traditional skiing tends to be short turns in the fall line or slow and wide traverses. Carving involves high speed traverses almost 90' to the fall line with the risk of almost head on collisions between two skiers carving out of sync. The whole point of carving is that it is a very efficient turn that loses little of the skiers speed.
@tangowaggon, to some extent that is true of course but I still feel more threatened by people who ski too fast on firm pistes without committing to finding an edge properly but instead bank on belting down to where the piste flattens out and their limited skills and excess confidence will allow them to stop.
... I do like carving but I recognise that there are significantly higher risks of collision with the technique.
I see relatively few people carving clean turns, certainly on anything steeper than an easy blue piste. The problem with skiers who may cause collisions because they are skiing too fast is one of a lack of personal responsibility not an absence (or acquisition) of a particular skill. It has nothing to do with them being on race-inspired carving skis, or fat skis or rockered skis, etc. The skiers who frighten me the most are the ones straightlining the slope, then throwing in a sudden pivoted turn to change direction and possibly check their speed.
... I still feel more threatened by people who ski too fast on firm pistes without committing to finding an edge properly but instead bank on belting down to where the piste flattens out and their limited skills and excess confidence will allow them to stop.
Exactly the situation which led to me being airlifted to hospital last December. An out of control punter unable to control his speed on a firm piste was the problem, not the junior racers who were carving clean turns and skiing much quicker but were skilled (and respectful) enough to not be a danger to other slope users.
The skiers who frighten me the most are the ones straightlining the slope, then throwing in a sudden pivoted turn to change direction and possibly check their speed.
Me too. My 2 last days up the Grands Montets I felt they should have "done something" - flat, smooth hard pack/ice (in places literally like an ice rink) and lots of people with no clue. I gave up for my own self preservation (off piste without going up glacier was refrozen melt).
I like to carve wide turns on my board, often putting a surfing-style "climb and drop" halfway across the face and before my heelside turn I sometimes kill a bit of speed by turning uphill. Of course, on a board you have a clear view uphill every other turn and I only use the piste like this when it's clear. However, in January I did end up in hospital after a concussion which I will never know the cause of. I had a blackout from 200m above the lift until being stood near the lift thinking "what just happened"? A bit of edge damage on my new board suggests someone hit me but they would have had to been straightlining very fast for me not to have seen them. It's also possible I just wiped out and hadn't noticed the damage.
Hmmm, @jedster, yes, that too. I try and stay off piste when descending, when possible.
@jedster, That run scares me. 4pm onwards every day you're running the gauntlet.
@dp, tbh any time of the day you can get caught.
Bring back the 'Wedel' !
@dp, i just think it's worse!
I have to agree with Ginge here but only because on his first outing on his new skis he found the edges a little too well and whilst I stood off the side of the piste waiting for him he caught an edge and I was a pubic hair away from being Tango'd by 6ft something out of control tangerine shouting sshhhiiiitttttttt!!
I'm with you here!! I ski fast but never see the enjoyment in straight lining it!
We all know someone who only does this.
Hansi Hinterseer vs. Ted Ligety. Interesting idea.
Next season I am off to easiski at LDA to tidy up my skiing on steep slopes. I am with the concern on this thread about flat-lining skiers out of control. There were some around even on the blue Signal run at LDA last season. That's a delightful, wide open run - lots of room for all to do anything under control. But you can certainly build up speed, and the odd flat-liner kept me wary - and if someone as competent as you can get caught, even the most wary of us is at risk.


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Le boulevard de la Cambre (en néerlandais : ) est une artère qui relie l'avenue Legrand au rond-point de l'Étoile dans les communes de Bruxelles et Ixelles.

Situation et accès

Notes et références

Voir aussi

Articles connexes
 Liste des rues de Bruxelles-ville
 Liste des rues d'Ixelles
 Abbaye de la Cambre
 La Truffe Noire

Boulevard à Bruxelles
Boulevard à Ixelles

redpajama_set_name: RedPajamaWikipedia


text:
Harvard Medical School Email Format
Harvard Medical School uses these email formats.
Harvard Medical School's Email Format
Harvard Medical School CEO, CFO, CTO, CMO Email and Phone Number
Harvard Medical School employs 4331 employees.
Natasha o'brown
Post doctoral research fellow
Jamaica plain, massachusetts, united states
 ***************@gmail.com, ***************@gmail.com
John goodson
Cambridge, massachusetts, united states
Harmon khela
Summer research scholar
Sacramento, california, united states
Marc normandin
Assistant professor of radiology and assistant physicist at massachusetts general hospital
 *********@ieee.org, *********@ieee.org
Jinmin gao
 **********@harvard.edu, **********@harvard.edu, **********@harvard.edu
Crystal evans
Staff assistant
Alba asins
Postdoctoral scientist
Harvard Medical School Information
Email formats, Phone Number, CEO CTO CFO COO CMO email of Harvard Medical School
Location: Boston, Massachusetts, United States
Industry: Higher Education
Headquarters: Boston, Massachusetts, United States
Linkedin: linkedin.com/company/harvard-medical-school
Companies like Harvard Medical School
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Equality & Refugee Law Clinics De L'ulb
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Núcleo De Estudantes De Ciências Biomédicas
Instituto De La Grasa
Akdeniz üniversitesi Gastronomi Topluluğu
Institute For Informatics At Washington University In St. Louis


text:
Q: Process.Start within application bundle on Mac (using MonoMac) I am using MonoMac do develop a very simple application for Mac. I have a solution consisting of two projects: the main project, and the auto updater. The main project references the auto updater, so that the auto updater becomes a part of the application bundle of the main application.
When running the main application, I want to launch the auto updater if there is a new update. On windows, this is a simple Process.Start("C:\path\to\updater.exe"); On Mac, however, this seems to be problematic. When doing it the above mentioned way (both when using absolute and relative paths to the updater.exe), nothing happens, and debugging simply says that the process has been ended already when I try to get any information.
I have attempted to launch the updater using AppleScript:
do shell script "mono /path/to/bundle.app/Contents/MonoBundle/updater.exe"

But this produces the error "No Info.plist file in application bundle or no NSPrincipalClass in the Info.plist file, exiting". This same error appears when I try to start the main executable the same way, and I know that the Info.plist is configured correctly for this (since I am indeed able to start the app), so there must be something else that is wrong.
Am I doing something obviously wrong? I just want to start the updater from the main executable, how I do it doesn't matter.

redpajama_set_name: RedPajamaStackExchange


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L ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS
L01X
L01XC
L01XC03
Zercepac 60 mg powder for concentrate for solution for infusion
One vial contains 60 mg of trastuzumab, a humanised IgG1 monoclonal antibody produced by mammalian (Chinese hamster ovary) cell suspension culture and purified by affinity and ion exchange chromatography including specific viral inactivation and removal procedures.
The reconstituted Zercepac solution contains 21 mg/mL of trastuzumab.
Powder for concentrate for solution for infusion.
White to pale yellow lyophilised powder.
Zercepac is indicated for the treatment of adult patients with HER2 positive metastatic breast cancer (MBC):
- as monotherapy for the treatment of those patients who have received at least two chemotherapy regimens for their metastatic disease. Prior chemotherapy must have included at least an anthracycline and a taxane unless patients are unsuitable for these treatments. Hormone receptor positive patients must also have failed hormonal therapy, unless patients are unsuitable for these treatments.
- in combination with paclitaxel for the treatment of those patients who have not received chemotherapy for their metastatic disease and for whom an anthracycline is not suitable.
- in combination with docetaxel for the treatment of those patients who have not received chemotherapy for their metastatic disease.
- in combination with an aromatase inhibitor for the treatment of postmenopausal patients with hormone-receptor positive MBC, not previously treated with trastuzumab.
Early breast cancer
Zercepac is indicated for the treatment of adult patients with HER2 positive early breast cancer (EBC).
- following surgery, chemotherapy (neoadjuvant or adjuvant) and radiotherapy (if applicable) (see section 5.1).
- following adjuvant chemotherapy with doxorubicin and cyclophosphamide, in combination with paclitaxel or docetaxel.
- in combination with adjuvant chemotherapy consisting of docetaxel and carboplatin.
- in combination with neoadjuvant chemotherapy followed by adjuvant Zercepac therapy, for locally advanced (including inflammatory) disease or tumours > 2 cm in diameter (see sections 4.4 and 5.1).
Zercepac should only be used in patients with metastatic or early breast cancer whose tumours have either HER2 overexpression or HER2 gene amplification as determined by an accurate and validated assay (see sections 4.4 and 5.1).
Metastatic gastric cancer
Zercepac in combination with capecitabine or 5-fluorouracil and cisplatin is indicated for the treatment of adult patients with HER2 positive metastatic adenocarcinoma of the stomach or gastro-oesophageal junction who have not received prior anti-cancer treatment for their metastatic disease.
Zercepac should only be used in patients with metastatic gastric cancer (MGC) whose tumours have HER2 overexpression as defined by IHC2+ and a confirmatory SISH or FISH result, or by an IHC 3+ result. Accurate and validated assay methods should be used (see sections 4.4 and 5.1).
HER2 testing is mandatory prior to initiation of therapy (see sections 4.4 and 5.1). Zercepac treatment should only be initiated by a physician experienced in the administration of cytotoxic chemotherapy (see section 4.4) and should be administered by a healthcare professional only.
Zercepac intravenous formulation is not intended for subcutaneous administration and should be administered via an intravenous infusion only.
In order to prevent medication errors, it is important to check the vial labels to ensure that the medicinal product being prepared and administered is Zercepac (trastuzumab) and not Kadcyla (trastuzumab emtansine).
Three-weekly schedule
The recommended initial loading dose is 8 mg/kg body weight. The recommended maintenance dose at three-weekly intervals is 6 mg/kg body weight, beginning three weeks after the loading dose.
The recommended initial loading dose of Zercepac is 4 mg/kg body weight. The recommended weekly maintenance dose of Zercepac is 2 mg/kg body weight, beginning one week after the loading dose.
Administration in combination with paclitaxel or docetaxel
In the pivotal trials (H0648g, M77001), paclitaxel or docetaxel was administered the day following the first dose of trastuzumab (for dose, see the Summary of Product Characteristics (SmPC) for paclitaxel or docetaxel) and immediately after the subsequent doses of trastuzumab if the preceding dose of trastuzumab was well tolerated.
Administration in combination with an aromatase inhibitor
In the pivotal trial (BO16216) trastuzumab and anastrozole were administered from day 1. There were no restrictions on the relative timing of trastuzumab and anastrozole at administration (for dose, see the SmPC for anastrozole or other aromatase inhibitors).
Three-weekly and weekly schedule
As a three-weekly regimen the recommended initial loading dose of Zercepac is 8 mg/kg body weight. The recommended maintenance dose of Zercepac at three-weekly intervals is 6 mg/kg body weight, beginning three weeks after the loading dose.
As a weekly regimen (initial loading dose of 4 mg/kg followed by 2 mg/kg every week) concomitantly with paclitaxel following chemotherapy with doxorubicin and cyclophosphamide.
See section 5.1 for chemotherapy combination dosing.
Breast cancer and gastric cancer
Duration of treatment
Patients with MBC or MGC should be treated with Zercepac until progression of disease.
Patients with EBC should be treated with Zercepac for 1 year or until disease recurrence, whichever occurs first; extending treatment in EBC beyond one year is not recommended (see section 5.1).
Dose reduction
No reductions in the dose of Zercepac were made during clinical trials. Patients may continue therapy during periods of reversible, chemotherapy-induced myelosuppression but they should be monitored carefully for complications of neutropenia during this time. Refer to the SmPC for paclitaxel, docetaxel or aromatase inhibitor for information on dose reduction or delays.
If left ventricular ejection fraction (LVEF) percentage drops ≥ 10 points from baseline AND to below 50%, treatment should be suspended and a repeat LVEF assessment performed within approximately 3 weeks. If LVEF has not improved, or has declined further, or if symptomatic congestive heart failure (CHF) has developed, discontinuation of Zercepac should be strongly considered, unless the benefits for the individual patient are deemed to outweigh the risks. All such patients should be referred for assessment by a cardiologist and followed up.
Missed doses
If the patient has missed a dose of Zercepac by one week or less, then the usual maintenance dose (weekly regimen: 2 mg/kg; three-weekly regimen: 6 mg/kg) should be administered as soon as possible. Do not wait until the next planned cycle. Subsequent maintenance doses should be administered 7 days or 21 days later according to the weekly or three-weekly schedules, respectively.
If the patient has missed a dose of Zercepac by more than one week, a re-loading dose of Zercepac should be administered over approximately 90 minutes (weekly regimen: 4 mg/kg; three-weekly regimen: 8 mg/kg) as soon as possible. Subsequent Zercepac maintenance doses (weekly regimen: 2 mg/kg; three-weekly regimen 6 mg/kg respectively) should be administered 7 days or 21 days later according to the weekly or three-weekly schedules respectively.
Dedicated pharmacokinetic studies in the elderly and those with renal or hepatic impairment have not been carried out. In a population pharmacokinetic analysis, age and renal impairment were not shown to affect trastuzumab disposition.
There is no relevant use of Zercepac in the paediatric population.
Zercepac is for intravenous use only. The loading dose should be administered as a 90-minute intravenous infusion. Do not administer as an intravenous push or bolus. Zercepac intravenous infusion should be administered by a healthcare provider prepared to manage anaphylaxis and an emergency kit should be available. Patients should be observed for at least six hours after the start of the first infusion and for two hours after the start of the subsequent infusions for symptoms like fever and chills or other infusion-related symptoms (see sections 4.4 and 4.8). Interruption or slowing the rate of the infusion may help control such symptoms. The infusion may be resumed when symptoms abate.
If the initial loading dose was well tolerated, the subsequent doses can be administered as a 30-minute infusion.
For instructions on reconstitution of Zercepac intravenous formulation before administration, see section 6.6.
• Hypersensitivity to trastuzumab, murine proteins, or to any of the excipients listed in section 6.1
• Severe dyspnoea at rest due to complications of advanced malignancy or requiring supplementary oxygen therapy.
In order to improve traceability of biological medicinal products, the trade name and the batch number of the administered product should be clearly recorded.
HER2 testing must be performed in a specialised laboratory which can ensure adequate validation of the testing procedures (see section 5.1).
Currently no data from clinical trials are available on re-treatment of patients with previous exposure to Zercepac in the adjuvant setting.
Cardiac dysfunction
Patients treated with Zercepac are at increased risk for developing CHF (New York Heart Association [NYHA] Class II-IV) or asymptomatic cardiac dysfunction. These events have been observed in patients receiving trastuzumab therapy alone or in combination with paclitaxel or docetaxel, particularly following anthracycline (doxorubicin or epirubicin) containing chemotherapy. These may be moderate to severe and have been associated with death (see section 4.8). In addition, caution should be exercised in treating patients with increased cardiac risk, e.g. hypertension, documented coronary artery disease, CHF, LVEF of <55%, older age.
All candidates for treatment with Zercepac, but especially those with prior anthracycline and cyclophosphamide (AC) exposure, should undergo baseline cardiac assessment including history and physical examination, electrocardiogram (ECG), echocardiogram, and/or multigated acquisition (MUGA) scan or magnetic resonance imaging. Monitoring may help to identify patients who develop cardiac dysfunction. Cardiac assessments, as performed at baseline, should be repeated every 3 months during treatment and every 6 months following discontinuation of treatment until 24 months from the last administration of Zercepac. A careful risk-benefit assessment should be made before deciding to treat with Zercepac.
Trastuzumab may persist in the circulation for up to 7 months after stopping Zercepac treatment based on population pharmacokinetic analysis of all available data (see section 5.2). Patients who receive anthracyclines after stopping Zercepac may possibly be at increased risk of cardiac dysfunction. If possible, physicians should avoid anthracycline-based therapy for up to 7 months after stopping Zercepac. If anthracyclines are used, the patient's cardiac function should be monitored carefully.
Formal cardiological assessment should be considered in patients in whom there are cardiovascular concerns following baseline screening. In all patients cardiac function should be monitored during treatment (e.g. every 12 weeks). Monitoring may help to identify patients who develop cardiac dysfunction. Patients who develop asymptomatic cardiac dysfunction may benefit from more frequent monitoring (e.g. every 6 - 8 weeks). If patients have a continued decrease in left ventricular function, but remain asymptomatic, the physician should consider discontinuing therapy if no clinical benefit of Zercepac therapy has been seen.
The safety of continuation or resumption of Zercepac in patients who experience cardiac dysfunction has not been prospectively studied. If LVEF percentage drops ≥10 points from baseline AND to below 50%, treatment should be suspended and a repeat LVEF assessment performed within approximately 3 weeks. If LVEF has not improved, or declined further, or symptomatic CHF has developed, discontinuation of Zercepac should be strongly considered, unless the benefits for the individual patient are deemed to outweigh the risks. All such patients should be referred for assessment by a cardiologist and followed up.
If symptomatic cardiac failure develops during Zercepac therapy, it should be treated with standard medicinal products for CHF. Most patients who developed CHF or asymptomatic cardiac dysfunction in pivotal trials improved with standard CHF treatment consisting of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) and a beta-blocker. The majority of patients with cardiac symptoms and evidence of a clinical benefit of trastuzumab treatment continued on therapy without additional clinical cardiac events.
Zercepac and anthracyclines should not be given concurrently in combination in the MBC setting.
Patients with MBC who have previously received anthracyclines are also at risk of cardiac dysfunction with Zercepac treatment, although the risk is lower than with concurrent use of Zercepac and anthracyclines.
For patients with EBC, cardiac assessments, as performed at baseline, should be repeated every 3 months during treatment and every 6 months following discontinuation of treatment until 24 months from the last administration of Zercepac. In patients who receive anthracycline-containing chemotherapy further monitoring is recommended, and should occur yearly up to 5 years from the last administration of Zercepac, or longer if a continuous decrease of LVEF is observed.
Patients with history of myocardial infarction (MI), angina pectoris requiring medical treatment, history of or existing CHF (NYHA Class II –IV), LVEF of <55%, other cardiomyopathy, cardiac arrhythmia requiring medical treatment, clinically significant cardiac valvular disease, poorly controlled hypertension (hypertension controlled by standard medical treatment eligible), and hemodynamic effective pericardial effusion were excluded from adjuvant and neoadjuvant EBC pivotal trials with trastuzumab and therefore treatment cannot be recommended in such patients.
Adjuvant treatment
Zercepac and anthracyclines should not be given concurrently in combination in the adjuvant treatment setting.
In patients with EBC an increase in the incidence of symptomatic and asymptomatic cardiac events was observed when trastuzumab was administered after anthracycline-containing chemotherapy compared to administration with a non-anthracycline regimen of docetaxel and carboplatin and was more marked when trastuzumab was administered concurrently with taxanes than when administered sequentially to taxanes. Regardless of the regimen used, most symptomatic cardiac events occurred within the first 18 months. In one of the 3 pivotal studies conducted in which a median follow-up of 5.5 years was available (BCIRG006) a continuous increase in the cumulative rate of symptomatic cardiac or LVEF events was observed in patients who were administered trastuzumab concurrently with a taxane following anthracycline therapy up to 2.37% compared to approximately 1% in the two comparator arms (anthracycline plus cyclophosphamide followed by taxane and taxane, carboplatin and trastuzumab).
Risk factors for a cardiac event identified in four large adjuvant studies included advanced age (>50 years), low LVEF (<55%) at baseline, prior to or following the initiation of paclitaxel treatment, decline in LVEF by 10-15 points, and prior or concurrent use of anti-hypertensive medicinal products. In patients receiving trastuzumab after completion of adjuvant chemotherapy, the risk of cardiac dysfunction was associated with a higher cumulative dose of anthracycline given prior to initiation of trastuzumab and a body mass index (BMI) >25 kg/m2.
Neoadjuvant-adjuvant treatment
In patients with EBC eligible for neoadjuvant-adjuvant treatment, Zercepac should be used concurrently with anthracyclines only in chemotherapy-naive patients and only with low-dose anthracycline regimens i.e. maximum cumulative doses of doxorubicin 180 mg/m2 or epirubicin 360 mg/m2.
If patients have been treated concurrently with a full course of low-dose anthracyclines and Zercepac in the neoadjuvant setting, no additional cytotoxic chemotherapy should be given after surgery. In other situations, the decision on the need for additional cytotoxic chemotherapy is determined based on individual factors.
Experience of concurrent administration of trastuzumab with low dose anthracycline regimens is currently limited to two trials (MO16432 and BO22227).
In the pivotal trial MO16432, trastuzumab was administered concurrently with neoadjuvant chemotherapy containing three cycles of doxorubicin (cumulative dose 180 mg/m2).
The incidence of symptomatic cardiac dysfunction was 1.7% in the trastuzumab arm.
In the pivotal trial BO22227, trastuzumab was administered concurrently with neoadjuvant chemotherapy that contained four cycles of epirubicin (cumulative dose 300 mg/m2); at a median follow-up exceeding 70 months, the incidence of congestive cardiac failure was 0.3% in the trastuzumab intravenous arm.
Clinical experience is limited in patients above 65 years of age.
Infusion-related reactions (IRRs) and hypersensitivity
Serious IRRs to trastuzumab infusion including dyspnoea, hypotension, wheezing, hypertension, bronchospasm, supraventricular tachyarrhythmia, reduced oxygen saturation, anaphylaxis, respiratory distress, urticaria and angioedema have been reported (see section 4.8). Pre-medication may be used to reduce risk of occurrence of these events. The majority of these events occur during or within 2.5 hours of the start of the first infusion. Should an infusion reaction occur the infusion should be discontinued or the rate of infusion slowed and the patient should be monitored until resolution of all observed symptoms (see section 4.2). These symptoms can be treated with an analgesic/antipyretic such as meperidine or paracetamol, or an antihistamine such as diphenhydramine. The majority of patients experienced resolution of symptoms and subsequently received further infusions of trastuzumab. Serious reactions have been treated successfully with supportive therapy such as oxygen, beta- agonists, and corticosteroids. In rare cases, these reactions are associated with a clinical course culminating in a fatal outcome. Patients experiencing dyspnoea at rest due to complications of advanced malignancy and comorbidities may be at increased risk of a fatal infusion reaction. Therefore, these patients should not be treated with Zercepac (see section 4.3).
Initial improvement followed by clinical deterioration and delayed reactions with rapid clinical deterioration have also been reported. Fatalities have occurred within hours and up to one week following infusion. On very rare occasions, patients have experienced the onset of infusion symptoms and pulmonary symptoms more than six hours after the start of the trastuzumab infusion. Patients should be warned of the possibility of such a late onset and should be instructed to contact their physician if these symptoms occur.
Pulmonary events
Severe pulmonary events have been reported with the use of trastuzumab in the post-marketing setting (see section 4.8). These events have occasionally been fatal. In addition, cases of interstitial lung disease including lung infiltrates, acute respiratory distress syndrome, pneumonia, pneumonitis, pleural effusion, respiratory distress, acute pulmonary oedema and respiratory insufficiency have been reported. Risk factors associated with interstitial lung disease include prior or concomitant therapy with other anti-neoplastic therapies known to be associated with it such as taxanes, gemcitabine, vinorelbine and radiation therapy. These events may occur as part of an infusion-related reaction or with a delayed onset. Patients experiencing dyspnoea at rest due to complications of advanced malignancy and comorbidities may be at increased risk of pulmonary events. Therefore, these patients should not be treated with Zercepac (see section 4.3). Caution should be exercised for pneumonitis, especially in patients being treated concomitantly with taxanes.
No formal drug interaction studies have been performed. Clinically significant interactions between Zercepac and the concomitant medicinal products used in clinical trials have not been observed.
Effect of trastuzumab on the pharmacokinetics of other antineoplastic agents
Pharmacokinetic data from studies BO15935 and M77004 in women with HER2-positive MBC suggested that exposure to paclitaxel and doxorubicin (and their major metabolites 6-α hydroxyl- paclitaxel, POH, and doxorubicinol, DOL) was not altered in the presence of trastuzumab (8 mg/kg or 4 mg/kg IV loading dose followed by 6 mg/kg q3w or 2 mg/kg q1w IV, respectively).
However, trastuzumab may elevate the overall exposure of one doxorubicin metabolite, (7-deoxy-13 dihydro-doxorubicinone, D7D). The bioactivity of D7D and the clinical impact of the elevation of this metabolite was unclear.
Data from study JP16003, a single-arm study of trastuzumab (4 mg/kg IV loading dose and 2 mg/kg IV weekly) and docetaxel (60 mg/m2 IV) in Japanese women with HER2- positive MBC, suggested that concomitant administration of trastuzumab had no effect on the single dose pharmacokinetics of docetaxel. Study JP19959 was a substudy of BO18255 (ToGA) performed in male and female Japanese patients with advanced gastric cancer to study the pharmacokinetics of capecitabine and cisplatin when used with or without trastuzumab. The results of this substudy suggested that the exposure to the bioactive metabolites (e.g. 5-FU) of capecitabine was not affected by concurrent use of cisplatin or by concurrent use of cisplatin plus trastuzumab. However, capecitabine itself showed higher concentrations and a longer half-life when combined with trastuzumab. The data also suggested that the pharmacokinetics of cisplatin were not affected by concurrent use of capecitabine or by concurrent use of capecitabine plus trastuzumab.
Pharmacokinetic data from Study H4613g/GO01305 in patients with metastatic or locally advanced inoperable HER2-positive cancer suggested that trastuzumab had no impact on the PK of carboplatin.
Effect of antineoplastic agents on trastuzumab pharmacokinetics
By comparison of simulated serum trastuzumab concentrations after trastuzumab monotherapy (4 mg/kg loading/2 mg/kg q1w IV) and observed serum concentrations in Japanese women with HER2- positive MBC (study JP16003) no evidence of a PK effect of concurrent administration of docetaxel on the pharmacokinetics of trastuzumab was found.
Comparison of PK results from two Phase II studies (BO15935 and M77004) and one Phase III study (H0648g) in which patients were treated concomitantly with trastuzumab and paclitaxel and two Phase II studies in which trastuzumab was administered as monotherapy (W016229 and MO16982), in women with HER2-positive MBC indicates that individual and mean trastuzumab trough serum concentrations varied within and across studies but there was no clear effect of the concomitant administration of paclitaxel on the pharmacokinetics of trastuzumab. Comparison of trastuzumab PK data from Study M77004 in which women with HER2-positive MBC were treated concomitantly with trastuzumab, paclitaxel and doxorubicin to trastuzumab PK data in studies where trastuzumab was administered as monotherapy (H0649g) or in combination with anthracycline plus cyclophosphamide or paclitaxel (Study H0648g), suggested no effect of doxorubicin and paclitaxel on the pharmacokinetics of trastuzumab.
Pharmacokinetic data from Study H4613g/GO01305 suggested that carboplatin had no impact on the PK of trastuzumab.
The administration of concomitant anastrozole did not appear to influence the pharmacokinetics of trastuzumab.
Women of childbearing potential should be advised to use effective contraception during treatment with Zercepac and for 7 months after treatment has concluded (see section 5.2).
Reproduction studies have been conducted in Cynomolgus monkeys at doses up to 25 times that of the weekly human maintenance dose of 2 mg/kg trastuzumab intravenous formulation and have revealed no evidence of impaired fertility or harm to the foetus. Placental transfer of trastuzumab during the early (days 20–50 of gestation) and late (days 120-150 of gestation) foetal development period was observed. It is not known whether trastuzumab can affect reproductive capacity. As animal reproduction studies are not always predictive of human response, trastuzumab should be avoided during pregnancy unless the potential benefit for the mother outweighs the potential risk to the foetus.
In the post-marketing setting, cases of foetal renal growth and/or function impairment in association with oligohydramnios, some associated with fatal pulmonary hypoplasia of the foetus, have been reported in pregnant women receiving trastuzumab. Women who become pregnant should be advised of the possibility of harm to the foetus. If a pregnant woman is treated with Zercepac, or if a patient becomes pregnant while receiving Zercepac or within 7 months following the last dose of Zercepac, close monitoring by a multidisciplinary team is desirable.
A study conducted in lactating Cynomolgus monkeys at doses 25 times that of the weekly human maintenance dose of 2 mg/kg trastuzumab intravenous formulation demonstrated that trastuzumab is secreted in the milk. The presence of trastuzumab in the serum of infant monkeys was not associated with any adverse effects on their growth or development from birth to 1 month of age. It is not known whether trastuzumab is secreted in human milk. As human IgG1 is secreted into human milk, and the potential for harm to the infant is unknown, women should not breast-feed during Zercepac therapy and for 7 months after the last dose.
There is no fertility data available.
Zercepac has minor influence on the ability to drive or use machines (see section 4.8).
Dizziness and somnolence may occur during treatment with Zercepac (see section 4.8). Patients experiencing infusion-related symptoms (see section 4.4) should be advised not to drive and use machines until symptoms abate.
Amongst the most serious and/or common adverse reactions reported in trastuzumab usage to date are cardiac dysfunction, infusion-related reactions, haematotoxicity (in particular neutropenia), infections and pulmonary adverse reactions.
In this section, the following categories of frequency have been used: very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Presented in Table 1 are adverse reactions that have been reported in association with the use of intravenous trastuzumab alone or in combination with chemotherapy in pivotal clinical trials and in the post-marketing setting.
All the terms included are based on the highest percentage seen in pivotal clinical trials. In addition, terms reported in the post marketing setting are included in Table 1.
Table 1 Undesirable effects reported with intravenous trastuzumab monotherapy or in combination with chemotherapy in pivotal clinical trials (N = 8386) and in post-marketing
System organ class
Adverse reaction
Neutropenic sepsis
Neoplasms benign, malignant and unspecified (incl. Cysts and polyps)
Malignant neoplasm progression
Neoplasm progression
Febrile neutropenia
White blood cell count decreased/leukopenia
Hypoprothrombinaemia
+Anaphylactic reaction
+Anaphylactic shock
Weight decreased/Weight loss
Tumour lysis syndrome
Hyperkalaemia
1Tremor
Paraesthesia
Dysgeusia
Hypertonia
Lacrimation increased
Papilloedema
Retinal haemorrhage
Ear and labyrinth disorders
1Blood pressure decreased
1 Blood pressure increased
1 Heart beat irregular
1Cardiac flutter
Ejection fraction decreased*
+Cardiac failure (congestive)
+1Supraventricular tachyarrhythmia
1Palpitation
Pericardial effusion
Cardiogenic shock
Gallop rhythm present
Hot flush
+1Hypotension
Vasodilatation
Respiratory, thoracic and mediastinal disorders
+Dyspnoea
Rhinorrhoea
+Pneumonia
Lung disorder
+Pleural effusion
+1Wheezing
Pneumonitis
+Pulmonary fibrosis
+Respiratory distress
+Respiratory failure
+Lung infiltration
+Acute pulmonary oedema
+Acute respiratory distress syndrome
+Bronchospasm
+Hypoxia
+Oxygen saturation decreased
Laryngeal oedema
Orthopnoea
1 Lip swelling
Hepatocellular injury
Liver tenderness
1Swelling face
Palmar-plantar erythrodysaesthesia syndrome
Hyperhydrosis
Maculopapular rash
Onychoclasis
Musculoskeletal and connective tissue disorders
1Muscle tightness
Bone pain
Pain in extremity
Renal disorder
Glomerulonephritis membranous
Glomerulonephropathy
Pregnancy, puerperium and perinatal conditions
Oligohydramnios
Renal hypoplasia
Pulmonary hypoplasia
Reproductive system and breast disorders
Breast inflammation/mastitis
Asthenia
Influenza-like symptoms
Infusion related reaction
Pyrexia
Mucosal inflammation
Peripheral oedema
Injury, poisoning and procedural complications
+ Denotes adverse reactions that have been reported in association with a fatal outcome.
1 Denotes adverse reactions that are reported largely in association with Infusion-related reactions. Specific percentages for these are not available.
* Observed with combination therapy following anthracyclines and combined with taxanes
Congestive heart failure (NYHA Class II – IV) is a common adverse reaction associated with the use of trastuzumab and has been associated with a fatal outcome (see section 4.4). Signs and symptoms of cardiac dysfunction such as dyspnoea, orthopnoea, increased cough, pulmonary oedema, S3 gallop, or reduced ventricular ejection fraction, have been observed in patients treated with trastuzumab (see section 4.4).
In 3 pivotal clinical trials of adjuvant trastuzumab given in combination with chemotherapy, the incidence of grade 3/4 cardiac dysfunction (specifically symptomatic Congestive Heart Failure) was similar in patients who were administered chemotherapy alone (i.e. did not receive trastuzumab) and in patients who were administered trastuzumab sequentially after a taxane (0.3-0.4%). The rate was highest in patients who were administered trastuzumab concurrently with a taxane (2.0%). In the neoadjuvant setting, the experience of concurrent administration of trastuzumab and low dose anthracycline regimen is limited (see section 4.4).
When trastuzumab was administered after completion of adjuvant chemotherapy NYHA Class III-IV heart failure was observed in 0.6% of patients in the one-year arm after a median follow-up of 12 months. In study BO16348, after a median follow-up of 8 years the incidence of severe CHF (NYHA Class III & IV) in the trastuzumab 1 year treatment arm was 0.8%, and the rate of mild symptomatic and asymptomatic left ventricular dysfunction was 4.6%.
Reversibility of severe CHF (defined as a sequence of at least two consecutive LVEF values ≥50% after the event) was evident for 71.4% of trastuzumab-treated patients. Reversibility of mild symptomatic and asymptomatic left ventricular dysfunction was demonstrated for 79.5% of patients. Approximately 17% of cardiac dysfunction related events occurred after completion of trastuzumab.
In the pivotal metastatic trials of intravenous trastuzumab, the incidence of cardiac dysfunction varied between 9% and 12% when it was combined with paclitaxel compared with 1%-4% for paclitaxel alone. For monotherapy, the rate was 6% – 9%. The highest rate of cardiac dysfunction was seen in patients receiving trastuzumab concurrently with anthracycline/cyclophosphamide (27%), and was significantly higher than for anthracycline/cyclophosphamide alone (7%-10%). In a subsequent trial with prospective monitoring of cardiac function, the incidence of symptomatic CHF was 2.2% in patients receiving trastuzumab and docetaxel, compared with 0% in patients receiving docetaxel alone.
Most of the patients (79%) who developed cardiac dysfunction in these trials experienced an improvement after receiving standard treatment for CHF.
Infusion reactions, allergic-like reactions and hypersensitivity
It is estimated that approximately 40% of patients who are treated with trastuzumab will experience some form of infusion-related reaction. However, the majority of infusion-related reactions are mild to moderate in intensity (NCI-CTC grading system) and tend to occur earlier in treatment, i.e. during infusions one, two and three and lessen in frequency in subsequent infusions. Reactions include chills, fever, dyspnoea, hypotension, wheezing, bronchospasm, tachycardia, reduced oxygen saturation, respiratory distress, rash, nausea, vomiting and headache (see section 4.4). The rate of infusion-related reactions of all grades varied between studies depending on the indication, the data collection methodology, and whether trastuzumab was given concurrently with chemotherapy or as monotherapy.
Severe anaphylactic reactions requiring immediate additional intervention can occur usually during either the first or second infusion of trastuzumab (see section 4.4) and have been associated with a fatal outcome.
Anaphylactoid reactions have been observed in isolated cases.
Haematotoxicity
Febrile neutropenia, leukopenia, anaemia, thrombocytopenia and neutropenia occurred very commonly. The frequency of occurrence of hypoprothrombinaemia is not known. The risk of neutropenia may be slightly increased when trastuzumab is administered with docetaxel following anthracycline therapy.
Severe pulmonary adverse reactions occur in association with the use of trastuzumab and have been associated with a fatal outcome. These include, but are not limited to, pulmonary infiltrates, acute respiratory distress syndrome, pneumonia, pneumonitis, pleural effusion, respiratory distress, acute pulmonary oedema and respiratory insufficiency (see section 4.4).
Details of risk minimisation measures that are consistent with the EU Risk Management Plan are presented in (section 4.4) Warnings and Precautions.
In the neoadjuvant-adjuvant EBC study (BO22227), at a median follow-up exceeding 70 months, 10.1% (30/296) of patients treated with trastuzumab intravenous developed antibodies against trastuzumab. Neutralizing anti-trastuzumab antibodies were detected in post-baseline samples in 2 of 30 patients in the trastuzumab intravenous arm.
The clinical relevance of these antibodies is not known. The presence of anti-trastuzumab antibodies had no impact on pharmacokinetics, efficacy (determined by pathological Complete Response [pCR] and event free survival [EFS]) and safety determined by occurrence of administration related reactions (ARRs) of trastuzumab intravenous.
There are no immunogenicity data available for trastuzumab in gastric cancer.
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.
There is no experience with overdose in human clinical trials. Single doses of Zercepac alone greater than 10 mg/kg have not been administered in the clinical trials; a maintenance dose of 10 mg/kg q3w following a loading dose of 8 mg/kg has been studied in a clinical trial with metastatic gastric cancer patients. Doses up to this level were well tolerated.
Pharmacotherapeutic group: Antineoplastic agents, monoclonal antibodies, ATC code: L01XC03
Zercepac is a biosimilar medicinal product.
Trastuzumab is a recombinant humanised IgG1 monoclonal antibody against the human epidermal growth factor receptor 2 (HER2). Overexpression of HER2 is observed in 20%-30% of primary breast cancers. Studies of HER2-positivity rates in gastric cancer (GC) using immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) or chromogenic in situ hybridization (CISH) have shown that there is a broad variation of HER2-positivity ranging from 6.8% to 34.0% for IHC and 7.1% to 42.6% for FISH. Studies indicate that breast cancer patients whose tumours overexpress HER2 have a shortened disease-free survival compared to patients whose tumours do not overexpress HER2. The extracellular domain of the receptor (ECD, p105) can be shed into the blood stream and measured in serum samples.
Trastuzumab binds with high affinity and specificity to sub-domain IV, a juxta-membrane region of HER2's extracellular domain. Binding of trastuzumab to HER2 inhibits ligand-independent HER2 signalling and prevents the proteolytic cleavage of its extracellular domain, an activation mechanism of HER2. As a result, trastuzumab has been shown, in both in vitro assays and in animals, to inhibit the proliferation of human tumour cells that overexpress HER2. Additionally, trastuzumab is a potent mediator of antibody-dependent cell-mediated cytotoxicity (ADCC). In vitro, trastuzumab-mediated ADCC has been shown to be preferentially exerted on HER2 overexpressing cancer cells compared with cancer cells that do not overexpress HER2.
Detection of HER2 overexpression or HER2 gene amplification
Detection of HER2 overexpression or HER2 gene amplification in breast cancer
Zercepac should only be used in patients whose tumours have HER2 overexpression or HER2 gene amplification as determined by an accurate and validated assay. HER2 overexpression should be detected using an immunohistochemistry (IHC)-based assessment of fixed tumour blocks (see section 4.4). HER2 gene amplification should be detected using fluorescence in situ hybridisation (FISH) or chromogenic in situ hybridisation (CISH) of fixed tumour blocks. Patients are eligible for Zercepac treatment if they show strong HER2 overexpression as described by a 3+ score by IHC or a positive FISH or CISH result.
To ensure accurate and reproducible results, the testing must be performed in a specialised laboratory, which can ensure validation of the testing procedures.
The recommended scoring system to evaluate the IHC staining patterns is as stated in Table 2:
Table 2 Recommended scoring system to evaluate the IHC staining patterns in breast cancer
Staining pattern
HER2 overexpression assessment
No staining is observed or membrane staining is observed in <10% of the tumour cells
A faint/barely perceptible membrane staining is detected in >10% of the tumour cells. The cells are only stained in part of their membrane.
A weak to moderate complete membrane staining is detected in >10% of the tumour cells.
Equivocal
Strong complete membrane staining is detected in
>10% of the tumour cells.
In general, FISH is considered positive if the ratio of the HER2 gene copy number per tumour cell to the chromosome 17 copy number is greater than or equal to 2, or if there are more than 4 copies of the HER2 gene per tumour cell if no chromosome 17 control is used.
In general, CISH is considered positive if there are more than 5 copies of the HER2 gene per nucleus in greater than 50% of tumour cells.
For full instructions on assay performance and interpretation please refer to the package inserts of validated FISH and CISH assays. Official recommendations on HER2 testing may also apply.
For any other method that may be used for the assessment of HER2 protein or gene expression, the analyses should only be performed by laboratories that provide adequate state-of-the-art performance of validated methods. Such methods must clearly be precise and accurate enough to demonstrate overexpression of HER2 and must be able to distinguish between moderate (congruent with 2+) and strong (congruent with 3+) overexpression of HER2.
Detection of HER2 over expression or HER2 gene amplification in gastric cancer
Only an accurate and validated assay should be used to detect HER2 over expression or HER2 gene amplification. IHC is recommended as the first testing modality and in cases where HER2 gene amplification status is also required, either a silver-enhanced in situ hybridization (SISH) or a FISH technique must be applied. SISH technology is however, recommended to allow for the parallel evaluation of tumour histology and morphology. To ensure validation of testing procedures and the generation of accurate and reproducible results, HER2 testing must be performed in a laboratory staffed by trained personnel. Full instructions on assay performance and results interpretation should be taken from the product information leaflet provided with the HER2 testing assays used.
In the ToGA (BO18255) trial, patients whose tumours were either IHC3+ or FISH positive were defined as HER2 positive and thus included in the trial. Based on the clinical trial results, the beneficial effects were limited to patients with the highest level of HER2 protein overexpression, defined by a 3+ score by IHC, or a 2+ score by IHC and a positive FISH result.
In a method comparison study (study D008548) a high degree of concordance (>95%) was observed for SISH and FISH techniques for the detection of HER2 gene amplification in gastric cancer patients.
HER2 over expression should be detected using an immunohistochemistry (IHC)-based assessment of fixed tumour blocks; HER2 gene amplification should be detected using in situ hybridisation using either SISH or FISH on fixed tumour blocks.
Table 3 Recommended scoring system to evaluate the IHC staining patterns in gastric cancer
Surgical specimen - staining pattern
Biopsy specimen – staining pattern
No reactivity or membranous reactivity in <10% of tumour cells
No reactivity or membranous reactivity in any tumour cell
Faint ⁄ barely perceptible membranous reactivity in ≥10% of tumour cells; cells are reactive only in part of their membrane
Tumour cell cluster with a faint ⁄ barely perceptible membranous reactivity irrespective of percentage of tumour cells stained
Weak to moderate complete, basolateral or lateral membranous reactivity in
≥10% of tumour cells
Tumour cell cluster with a weak to moderate complete, basolateral or lateral membranous reactivity irrespective of percentage of tumour cells stained
Strong complete, basolateral or lateral membranous reactivity in ≥10% of tumour cells
Tumour cell cluster with a strong complete, basolateral or lateral membranous reactivity irrespective of percentage of tumour cells stained
In general, SISH or FISH is considered positive if the ratio of the HER2 gene copy number per tumour cell to the chromosome 17 copy number is greater than or equal to 2.
Trastuzumab has been used in clinical trials as monotherapy for patients with MBC who have tumours that overexpress HER2 and who have failed one or more chemotherapy regimens for their metastatic disease (trastuzumab alone).
Trastuzumab has also been used in combination with paclitaxel or docetaxel for the treatment of patients who have not received chemotherapy for their metastatic disease. Patients who had previously received anthracycline-based adjuvant chemotherapy were treated with paclitaxel (175 mg/m2 infused over 3 hours) with or without trastuzumab. In the pivotal trial of docetaxel (100 mg/m2 infused over 1 hour) with or without trastuzumab, 60% of the patients had received prior anthracycline-based adjuvant chemotherapy. Patients were treated with trastuzumab until progression of disease.
The efficacy of trastuzumab in combination with paclitaxel in patients who did not receive prior adjuvant anthracyclines has not been studied. However, trastuzumab plus docetaxel was efficacious in patients whether or not they had received prior adjuvant anthracyclines.
The test method for HER2 overexpression used to determine eligibility of patients in the pivotal trastuzumab monotherapy and trastuzumab plus paclitaxel clinical trials employed immunohistochemical staining for HER2 of fixed material from breast tumours using the murine monoclonal antibodies CB11 and 4D5. These tissues were fixed in formalin or Bouin's fixative. This investigative clinical trial assay performed in a central laboratory utilised a 0 to 3+ scale. Patients classified as staining 2+ or 3+ were included, while those staining 0 or 1+ were excluded. Greater than 70% of patients enrolled exhibited 3+ overexpression. The data suggest that beneficial effects were greater among those patients with higher levels of overexpression of HER2 (3+).
The main test method used to determine HER2 positivity in the pivotal trial of docetaxel, with or without trastuzumab, was immunohistochemistry. A minority of patients was tested using fluorescence in-situ hybridisation (FISH). In this trial, 87% of patients entered had disease that was IHC3+, and 95% of patients entered had disease that was IHC3+ and/or FISH-positive.
Weekly dosing in metastatic breast cancer
The efficacy results from the monotherapy and combination therapy studies are summarised in Table 4:
Table 4 Efficacy results from the monotherapy and combination therapy studies
N=172
Trastuzumab
plus paclitaxel2
Paclitaxel2
plus docetaxel3
Docetaxel3
(9 - 27)
(95%CI)
Median duration of response (months) (95%CI)
(5.6-10.3)
(7.3-8.8)
Median TTP
(months) (95%CI)
Median Survival
(12.3-ne)
(18.6-33.7)
TTP = time to progression; "ne" indicates that it could not be estimated or it was not yet reached.
1. Study H0649g: IHC3+ patient subset
3. Study M77001: Full analysis set (intent-to-treat), 24 months results
Combination treatment with trastuzumab and anastrozole
Trastuzumab has been studied in combination with anastrozole for first line treatment of MBC in HER2 overexpressing, hormone-receptor (i.e. oestrogen-receptor (ER) and/or progesterone-receptor (PR)) positive postmenopausal patients. Progression free survival was doubled in the trastuzumab plus anastrozole arm compared to anastrozole (4.8 months versus 2.4 months). For the other parameters the improvements seen for the combination were for overall response (16.5% versus 6.7%); clinical benefit rate (42.7% versus 27.9%); time to progression (4.8 months versus 2.4 months). For time to response and duration of response no difference could be recorded between the arms. The median overall survival was extended by 4.6 months for patients in the combination arm. The difference was not statistically significant, however more than half of the patients in the anastrozole alone arm crossed over to a trastuzumab containing regimen after progression of disease.
Three -weekly dosing in metastatic breast cancer
The efficacy results from the non-comparative monotherapy and combination therapy studies are summarised in Table 5:
Table 5 Efficacy results from the non-comparative monotherapy and combination therapy studies
Trastuzumab plus paclitaxel3
Trastuzumab plus docetaxel4
Response rate (95%CI)
Median duration of response (months) (range)
(1.8-21)
Median TTP (months) (95%CI)
(6.2-ne)
Median Survival (months) (95%CI)
(32-ne)
1. Study WO16229: loading dose 8 mg/kg, followed by 6 mg/kg 3-weekly schedule
2. Study MO16982: loading dose 6 mg/kg weekly x 3; followed by 6 mg/kg 3-weekly schedule
3. Study BO15935
4. Study MO16419
Sites of progression
The frequency of progression in the liver was significantly reduced in patients treated with the combination of trastuzumab and paclitaxel, compared to paclitaxel alone (21.8% versus 45.7%; p=0.004). More patients treated with trastuzumab and paclitaxel progressed in the central nervous system than those treated with paclitaxel alone (12.6% versus 6.5%; p=0.377).
Early breast cancer (adjuvant setting)
Early breast cancer is defined as non-metastatic primary invasive carcinoma of the breast.
In the adjuvant treatment setting, trastuzumab was investigated in 4 large multicentre, randomised, trials.
- Study BO16348 was designed to compare one and two years of three-weekly trastuzumab treatment versus observation in patients with HER2 positive EBC following surgery, established chemotherapy and radiotherapy (if applicable). In addition, comparison of two years of trastuzumab treatment versus one year of trastuzumab treatment was performed. Patients assigned to receive trastuzumab were given an initial loading dose of 8 mg/kg, followed by 6 mg/kg every three weeks for either one or two years.
- The NSABP B-31 and NCCTG N9831 studies that comprise the joint analysis were designed to investigate the clinical utility of combining trastuzumab treatment with paclitaxel following AC chemotherapy, additionally the NCCTG N9831 study also investigated adding trastuzumab sequentially to AC→P chemotherapy in patients with HER2 positive EBC following surgery.
- The BCIRG 006 study was designed to investigate combining trastuzumab treatment with docetaxel either following AC chemotherapy or in combination with docetaxel and carboplatin in patients with HER2 positive EBC following surgery.
Early breast cancer in the HERA trial was limited to operable, primary, invasive adenocarcinoma of the breast, with axillary nodes positive or axillary nodes negative if tumours at least 1 cm in diameter.
In the joint analysis of the NSABP B-31 and NCCTG N9831 studies, EBC was limited to women with operable breast cancer at high risk, defined as HER2-positive and axillary lymph node positive or HER2 positive and lymph node negative with high risk features (tumour size >1 cm and ER negative or tumour size >2 cm, regardless of hormonal status).
In the BCIRG 006 study HER2 positive, EBC was defined as either lymph node positive or high risk node negative patients with no (pN0) lymph node involvement, and at least 1 of the following factors: tumour size greater than 2 cm, oestrogen receptor and progesterone receptor negative, histological and/or nuclear grade 2-3, or age <35 years.
The efficacy results from the BO16348 trial following 12 months* and 8 years** median follow-up are summarized in Table 6:
Table 6 Efficacy results from study BO16348
Median follow-up
12 months*
8 years**
N=1693
N= 1697***
N = 1702***
- No. patients with event
- No. patients without event
1474 (87.1%)
P-value versus Observation
< 0.0001
Hazard Ratio versus Observation
Recurrence-free survival
Distant disease-free survival
99 (5.8%)
Overall survival (death)
*Co-primary endpoint of DFS of 1 year versus observation met the pre-defined statistical boundary
**Final analysis (including crossover of 52% of patients from the observation arm to trastuzumab)
*** There is a discrepancy in the overall sample size due to a small number of patients who were randomized after the cut-off date for the 12-month median follow-up analysis
The efficacy results from the interim efficacy analysis crossed the protocol pre-specified statistical boundary for the comparison of 1-year of trastuzumab versus observation. After a median follow-up of 12 months, the hazard ratio (HR) for disease free survival (DFS) was 0.54 (95% CI 0.44, 0.67) which translates into an absolute benefit, in terms of a 2-year disease-free survival rate, of 7.6 percentage points (85.8% versus 78.2%) in favour of the trastuzumab arm.
A final analysis was performed after a median follow-up of 8 years, which showed that 1 year trastuzumab treatment is associated with a 24% risk reduction compared to observation only (HR=0.76, 95% CI 0.67, 0.86). This translates into an absolute benefit in terms of an 8 year disease free survival rate of 6.4 percentage points in favour of 1 year trastuzumab treatment.
In this final analysis, extending trastuzumab treatment for a duration of two years did not show additional benefit over treatment for 1 year [DFS HR in the intent to treat (ITT) population of 2 years versus 1 year=0.99 (95% CI: 0.87, 1.13), p-value=0.90 and OS HR=0.98 (0.83, 1.15); p-value=0.78]. The rate of asymptomatic cardiac dysfunction was increased in the 2-year treatment arm (8.1% versus 4.6% in the 1-year treatment arm). More patients experienced at least one grade 3 or 4 adverse event in the 2-year treatment arm (20.4%) compared with the 1-year treatment arm (16.3%).
In the NSABP B-31 and NCCTG N9831 studies trastuzumab was administered in combination with paclitaxel, following AC chemotherapy.
Doxorubicin and cyclophosphamide were administered concurrently as follows:
- intravenous push doxorubicin, at 60 mg/m2, given every 3 weeks for 4 cycles.
- intravenous cyclophosphamide, at 600 mg/m2 over 30 minutes, given every 3 weeks for 4 cycles.
Paclitaxel, in combination with trastuzumab, was administered as follows:
- intravenous paclitaxel - 80 mg/m2 as a continuous intravenous infusion, given every week for 12 weeks.
- intravenous paclitaxel - 175 mg/m2 as a continuous intravenous infusion, given every 3 weeks for 4 cycles (day 1 of each cycle).
The efficacy results from the joint analysis of the NSABP B-31 and NCCTG 9831 trials at the time of the definitive analysis of DFS* are summarized in Table 7. The median duration of follow up was 1.8 years for the patients in the AC→P arm and 2.0 years for patients in the AC→PH arm.
Table 7 Summary of efficacy results from the joint analysis of the NSABP B-31 and NCCTG N9831 trials at the time of the definitive DFS analysis*
AC→P
(n=1679)
AC→PH
Hazard ratio vs AC→P
(95% CI)
No. patients with event (%)
133 (8.0)
0.48 (0.39, 0.59)
p<0.0001
Distant recurrence
No. patients with event
Death (OS event):
p=0.014**
A: doxorubicin; C: cyclophosphamide; P: paclitaxel; H: trastuzumab
* At median duration of follow up of 1.8 years for the patients in the AC→P arm and 2.0 years for patients in the AC→PH arm
** p value for OS did not cross the pre-specified statistical boundary for comparison of AC→PH vs. AC→P
For the primary endpoint, DFS, the addition of trastuzumab to paclitaxel chemotherapy resulted in a 52% decrease in the risk of disease recurrence. The hazard ratio translates into an absolute benefit, in terms of 3-year disease-free survival rate estimates of 11.8 percentage points (87.2% versus 75.4%) in favour of the AC→PH (trastuzumab) arm.
At the time of a safety update after a median of 3.5-3.8 years follow up, an analysis of DFS reconfirms the magnitude of the benefit shown in the definitive analysis of DFS. Despite the cross-over to trastuzumab in the control arm, the addition of trastuzumab to paclitaxel chemotherapy resulted in a 52% decrease in the risk of disease recurrence. The addition of trastuzumab to paclitaxel chemotherapy also resulted in a 37% decrease in the risk of death.
The pre-planned final analysis of OS from the joint analysis of studies NSABP B-31 and NCCTG N9831 was performed when 707 deaths had occurred (median follow-up 8.3 years in the AC→P H group). Treatment with AC→PH resulted in a statistically significant improvement in OS compared with AC→P (stratified HR=0.64; 95% CI [0.55, 0.74]; log-rank p-value <0.0001). At 8 years, the survival rate was estimated to be 86.9% in the AC→PH arm and 79.4% in the AC→P arm, an absolute benefit of 7.4% (95% CI 4.9%, 10.0%).
The final OS results from the joint analysis of studies NSABP B-31 and NCCTG N9831 are summarized in Table 8 below:
Table 8 Final overall survival analysis from the joint analysis of trials NSABP B-31 and NCCTG N9831
p-value versus
Hazard Ratio versus AC→P (95% CI)
(0.55, 0.74)
DFS analysis was also performed at the final analysis of OS from the joint analysis of studies NSABP B-31 and NCCTG N9831. The updated DFS analysis results (stratified HR = 0.61; 95% CI [0.54, 0.69]) showed a similar DFS benefit compared to the definitive primary DFS analysis, despite 24.8% patients in the AC→P arm who crossed over to receive trastuzumab. At 8 years, the disease-free survival rate was estimated to be 77.2% (95% CI: 75.4, 79.1) in the AC→PH arm, an absolute benefit of 11.8% compared with the AC→P arm.
In the BCIRG 006 study trastuzumab was administered either in combination with docetaxel, following AC chemotherapy (AC→DH) or in combination with docetaxel and carboplatin (DCarbH).
Docetaxel was administered as follows:
- intravenous docetaxel - 100 mg/m2 as an intravenous infusion over 1 hour, given every 3 weeks for 4 cycles (day 2 of first docetaxel cycle, then day1 of each subsequent cycle)
- intravenous docetaxel - 75 mg/m2 as an intravenous infusion over 1 hour, given every 3 weeks for 6 cycles (day 2 of cycle 1, then day 1 of each subsequent cycle)
which was followed by:
- carboplatin – at target AUC = 6 mg/mL/min administered by intravenous infusion over 30-60 minutes repeated every 3 weeks for a total of six cycles
Trastuzumab was administered weekly with chemotherapy and 3 weekly thereafter for a total of 52 weeks.
The efficacy results from the BCIRG 006 are summarized in Tables 9 and 10. The median duration of follow up was 2.9 years in the AC→D arm and 3.0 years in each of the AC→DH and DCarbH arms.
Table 9 Overview of efficacy analyses BCIRG 006 AC→D versus AC→DH
AC→D
AC→DH
Hazard ratio vs AC→D
0.61 (0.49, 0.77) p<0.0001
Death (OS event)
p=0.0024
AC→D = doxorubicin plus cyclophosphamide, followed by docetaxel; AC→DH = doxorubicin plus cyclophosphamide, followed by docetaxel plus trastuzumab; CI = confidence interval
Table 10 Overview of efficacy analyses BCIRG 006 AC→D versus DCarbH
DCarbH
0.67 (0.54, 0.83) p=0.0003
AC→D = doxorubicin plus cyclophosphamide, followed by docetaxel; DCarbH = docetaxel, carboplatin and trastuzumab; CI = confidence interval
In the BCIRG 006 study for the primary endpoint, DFS, the hazard ratio translates into an absolute benefit, in terms of 3-year disease-free survival rate estimates of 5.8 percentage points (86.7% versus 80.9%) in favour of the AC→DH (trastuzumab) arm and 4.6 percentage points (85.5% versus 80.9%) in favour of the DCarbH (trastuzumab) arm compared to AC→D.
In study BCIRG 006, 213/1075 patients in the DCarbH (TCH) arm, 221/1074 patients in the AC→DH (AC→TH) arm, and 217/1073 in the AC→D (AC→T) arm had a Karnofsky performance status ≤90 (either 80 or 90). No disease-free survival (DFS) benefit was noticed in this subgroup of patients (hazard ratio = 1.16, 95% CI [0.73, 1.83] for DCarbH (TCH) versus AC→D (AC→T); hazard ratio 0.97, 95% CI [0.60, 1.55] for AC→DH (AC→TH) versus AC→D).
In addition a post-hoc exploratory analysis was performed on the data sets from the joint analysis (JA) NSABP B-31/NCCTG N9831* and BCIRG006 clinical studies combining DFS events and symptomatic cardiac events and summarised in Table 11:
Table 11 Post-hoc exploratory analysis results from the joint analysis NSABP B-31/NCCTG N9831* and BCIRG006 clinical studies combining DFS events and symptomatic cardiac events
(vs. AC→P) (NSABP B-31 and NCCTG N9831)
(vs. AC→D)
(BCIRG 006)
Primary efficacy analysis
DFS hazard ratios
p< 0.0001
Long term follow-up efficacy analysis**
Post-hoc exploratory analysis with DFS and symptomatic cardiac events
Long term follow-up** hazard ratios (95% CI)
A: doxorubicin; C: cyclophosphamide; P: paclitaxel; D: docetaxel; Carb: carboplatin; H: trastuzumab
CI = confidence interval
*At the time of the definitive analysis of DFS. Median duration of follow up was 1.8 years in the AC→P arm and 2.0 years in the AC→PH arm
** Median duration of long term follow-up for the Joint Analysis clinical studies was 8.3 years (range: 0.1 to 12.1) for the AC→PH arm and 7.9 years (range: 0.0 to 12.2) for the AC→P arm; Median duration of long term follow-up for the BCIRG 006 study was 10.3 years in both the AC→D arm (range: 0.0 to 12.6) arm and the DCarbH arm (range: 0.0 to 13.1), and was 10.4 years (range: 0.0 to 12.7) in the AC→DH arm
Early breast cancer (neoadjuvant-adjuvant setting)
So far, no results are available which compare the efficacy of trastuzumab administered with chemotherapy in the adjuvant setting with that obtained in the neo-adjuvant/adjuvant setting.
In the neoadjuvant-adjuvant treatment setting, study MO16432, a multicentre randomised trial, was designed to investigate the clinical efficacy of concurrent administration of trastuzumab with neoadjuvant chemotherapy including both an anthracycline and a taxane, followed by adjuvant trastuzumab, up to a total treatment duration of 1 year. The study recruited patients with newly diagnosed locally advanced (Stage III) or inflammatory EBC. Patients with HER2+ tumours were randomised to receive either neoadjuvant chemotherapy concurrently with neoadjuvant-adjuvant trastuzumab, or neoadjuvant chemotherapy alone.
In study MO16432, trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg maintenance every 3 weeks) was administered concurrently with 10 cycles of neoadjuvant chemotherapy
• Doxorubicin 60 mg/m2 and paclitaxel 150 mg/m2, administered 3-weekly for 3 cycles,
which was followed by
• Paclitaxel 175 mg/m2 administered 3-weekly for 4 cycles,
• CMF on day 1 and 8 every 4 weeks for 3 cycles
which was followed after surgery by
• additional cycles of adjuvant trastuzumab (to complete 1 year of treatment)
The efficacy results from Study MO16432 are summarized in Table 12. The median duration of follow-up in the trastuzumab arm was 3.8 years.
Table 12 Efficacy results from MO16432
Chemo + trastuzumab (n=115)
Chemo only (n=116)
Event-free survival
Hazard Ratio (95% CI)
Total pathological complete response* (95% CI)
20.7% (13.7, 29.2)
* defined as absence of any invasive cancer both in the breast and axillary nodes
An absolute benefit of 13 percentage points in favour of the trastuzumab arm was estimated in terms of 3-year event-free survival rate (65% versus 52%).
Trastuzumab has been investigated in one randomised, open-label phase III trial ToGA (BO18255) in combination with chemotherapy versus chemotherapy alone.
Chemotherapy was administered as follows:
- capecitabine - 1000 mg/m2 orally twice daily for 14 days every 3 weeks for 6 cycles (evening of day 1 to morning of day 15 of each cycle)
- intravenous 5-fluorouracil - 800 mg/m2/day as a continuous intravenous infusion over 5 days, given every 3 weeks for 6 cycles (days 1 to 5 of each cycle)
Either of which was administered with:
- cisplatin - 80 mg/m2 every 3 weeks for 6 cycles on day 1 of each cycle.
The efficacy results from study BO18225 are summarized in Table 13:
Table 13 Efficacy results from BO18225
FP +H
HR (95% CI)
Overall survival, Median months
0.74 (0.60-0.91)
Progression-free survival, Median months
Time to disease progression, Median months
Overall response rate, %
1.70a (1.22, 2.38)
Duration of response, Median months
FP + H: Fluoropyrimidine/cisplatin + trastuzumab
FP: Fluoropyrimidine/cisplatin
a Odds ratio
Patients were recruited to the trial who were previously untreated for HER2-positive inoperable locally advanced or recurrent and/or metastatic adenocarcinoma of the stomach or gastro-oesophageal junction not amenable to curative therapy. The primary endpoint was overall survival which was defined as the time from the date of randomization to the date of death from any cause. At the time of the analysis a total of 349 randomized patients had died: 182 patients (62.8%) in the control arm and 167 patients (56.8%) in the treatment arm. The majority of the deaths were due to events related to the underlying cancer.
Post-hoc subgroup analyses indicate that positive treatment effects are limited to targeting tumours with higher levels of HER2 protein (IHC 2+/FISH+ or IHC 3+). The median overall survival for the high HER2 expressing group was 11.8 months versus 16 months, HR 0.65 (95% CI 0.51-0.83) and the median progression free survival was 5.5 months versus 7.6 months, HR 0.64 (95% CI 0.51-0.79) for FP versus FP + H, respectively. For overall survival, the HR was 0.75 (95% CI 0.51-1.11) in the IHC 2+/FISH+ group and the HR was 0.58 (95% CI 0.41-0.81) in the IHC 3+/FISH+ group.
In an exploratory subgroup analysis performed in the TOGA (BO18255) trial there was no apparent benefit on overall survival with the addition of trastuzumab in patients with ECOG PS 2 at baseline [HR 0.96 (95% CI 0.51-1.79)], non-measurable [HR 1.78 (95% CI 0.87-3.66)] and locally advanced disease [HR 1.20 (95% CI 0.29-4.97)].
The European Medicines Agency has waived the obligation to submit the results of studies with trastuzumab in all subsets of the paediatric population for breast and gastric cancer (see section 4.2 for information on paediatric use).
The pharmacokinetics of trastuzumab were evaluated in a population pharmacokinetic model analysis using pooled data from 1,582 subjects, including patients with HER2 positive MBC, EBC, AGC or other tumour types, and healthy volunteers, in 18 Phase I, II and III trials receiving trastuzumab intravenous. A two-compartment model with parallel linear and non-linear elimination from the central compartment described the trastuzumab concentration-time profile. Due to non-linear elimination, total clearance increased with decreasing concentration. Therefore, no constant value for half-life of trastuzumab can be deduced. The t1/2 decreases with decreasing concentrations within a dosing interval (see Table 16). MBC and EBC patients had similar PK parameters (e.g. clearance (CL), the central compartment volume (Vc)) and population-predicted steady-state exposures (Cmin, Cmax and AUC). Linear clearance was 0.136 L/day for MBC, 0.112 L/day for EBC and 0.176 L/day for AGC. The non-linear elimination parameter values were 8.81 mg/day for the maximum elimination rate (Vmax) and 8.92 mcg/mL for the Michaelis-Menten constant (Km) for the MBC, EBC, and AGC patients. The central compartment volume was 2.62 L for patients with MBC and EBC and 3.63 L for patients with AGC. In the final population PK model, in addition to primary tumour type, body-weight, serum aspartate aminotransferase and albumin were identified as a statistically significant covariates affecting the exposure of trastuzumab. However, the magnitude of effect of these covariates on trastuzumab exposure suggests that these covariates are unlikely to have a clinically meaningful effect on trastuzumab concentrations.
The population predicted PK exposure values (median with 5th - 95th percentiles) and PK parameter values at clinically relevant concentrations (Cmax and Cmin) for MBC, EBC and AGC patients treated with the approved q1w and q3w dosing regimens are shown in Table 14 (Cycle 1), Table 15 (steady- state), and Table 16 (PK parameters).
Table 14 Population predicted cycle 1 PK exposure values (median with 5th - 95th percentiles) for trastuzumab intravenous dosing regimens in MBC, EBC and AGC patients
Primary tumour type
Cmin (mcg/mL)
Cmax (mcg/mL)
AUC0-21days (mcg.day/mL)
8mg/kg + 6mg/kg q3w
(2.9 - 46.3)
(728 - 1998)
(18.7 - 45.5)
(84.2 – 225)
4mg/kg + 2mg/kg qw
(49.4 - 114)
Table 15 Population predicted steady state PK exposure values (median with 5th - 95th percentiles) for trastuzumab intravenous dosing regimens in MBC, EBC and AGC patients
Primary tumourtype
ss* (mcg/mL)
ss**
AUCss, 0-21days (mcg.day/mL)
Time to steady- state*** (week)
8 mg/kg + 6 mg/kg q3w
(1332 -2771)
(72.5 -251)
4 mg/kg + 2 mg/kg qw
*Cmin,ss – Cmin at steady state
**Cmax,ss = Cmax at steady state
*** time to 90% of steady-state
Table 16 Population predicted PK parameter values at steady state for trastuzumab intravenous dosing regimens in MBC, EBC and AGC patients
Total CL range from Cmax
ss to Cmin
ss (L/day)
t1/2 range from Cmax
ss (day)
Trastuzumab washout
Trastuzumab washout period was assessed following q1w or q3w intravenous administration using the population PK model. The results of these simulations indicate that at least 95% of patients will reach concentrations that are <1 mcg/mL (approximately 3% of the population predicted Cmin,ss, or about 97% washout) by 7 months.
Circulating shed HER2 ECD
The exploratory analyses of covariates with information in only a subset of patients suggested that patients with greater shed HER2-ECD level had faster nonlinear clearance (lower Km) (P <0.001). There was a correlation between shed antigen and SGOT/AST levels; part of the impact of shed antigen on clearance may have been explained by SGOT/AST levels.
Baseline levels of the shed HER2-ECD observed in MGC patients were comparable to those in MBC and EBC patients and no apparent impact on trastuzumab clearance was observed.
There was no evidence of acute or multiple dose-related toxicity in studies of up to 6 months, or reproductive toxicity in teratology, female fertility or late gestational toxicity/placental transfer studies. Zercepac is not genotoxic. A study of trehalose, a major formulation excipient did not reveal any toxicities.
No long-term animal studies have been performed to establish the carcinogenic potential of Zercepac, or to determine its effects on fertility in males.
L-histidine hydrochloride monohydrate
L-histidine
α, α-trehalose dihydrate
This medicinal product must not be mixed or diluted with other medicinal products except those mentioned under section 6.6.
Do not dilute with glucose solutions since these cause aggregation of the protein.
Unopened vial
After reconstitution and dilution
After aseptic reconstitution with sterile water for injection, chemical and physical stability of the reconstituted solution has been demonstrated for 48 hours at 2°C – 8°C.
After aseptic dilution in polyethylene or polypropylene bags containing sodium chloride 9 mg/mL (0.9%) solution for injection, chemical and physical stability of Zercepac has been demonstrated for up to 84 days at 2°C – 8°C, 7 days at 23°C – 27°C and 24 hours at 30°C.
From a microbiological point of view, the reconstituted solution and Zercepac infusion solution should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user, unless reconstitution have taken place under controlled and validated aseptic conditions.
Do not freeze the reconstituted solution.
Store in a refrigerator (2°C – 8°C).
For storage conditions of the reconstituted and diluted medicinal product, see section 6.3.
One 10 mL clear glass type I vial with bromobutyl rubber stopper containing 60 mg of trastuzumab.
Each carton contains one vial.
Zercepac is provided in sterile, preservative-free, non-pyrogenic, single use vials.
Since the medicinal product does not contain any anti-microbial preservative or bacteriostatic agents, appropriate aseptic technique should be used for reconstitution and dilution procedures. Care must be taken to ensure the sterility of prepared solutions.
Aseptic preparation, handling and storage:
The infusion preparation should be:
• performed by trained personnel in accordance with good practice rules especially with respect to the aseptic preparation of parenteral products.
• prepared in a laminar flow hood or biological safety cabinet using standard precautions for the safe handling of intravenous agents.
• followed by adequate storage of the prepared solution for intravenous infusion to ensure maintenance of the aseptic conditions.
Instructions for aseptic reconstitution:
1) Using a sterile syringe, slowly inject the appropriate volume (as noted below) of sterile water for injection (not supplied) in the vial containing the lyophilised Zercepac, directing the stream into the lyophilised cake. Use of other reconstitution solvents should be avoided.
2) Swirl the vial gently to aid reconstitution. DO NOT SHAKE!
Slight foaming of the product upon reconstitution is not unusual. Allow the vial to stand undisturbed for approximately 5 minutes. The reconstituted Zercepac results in a colourless to pale yellow transparent solution and should be essentially free of visible particulates.
Reconstitution of the 60 mg vial with 3.0 mL of sterile water for injection yields a 3.1 mL solution for single-dose use, containing approximately 21 mg/mL trastuzumab, at a pH of approximately 6.0. A volume overage of 8% ensures that the labelled dose of 60 mg can be withdrawn from each vial.
The reconstituted solution should not be frozen.
Instructions for aseptic dilution of the reconstituted solution
Determine the volume of the solution required:
• based on a loading dose of 4 mg trastuzumab/kg body weight, or a subsequent weekly dose of 2 mg trastuzumab/kg body weight:
Volume (mL) = Body weight (kg) x dose (4 mg/kg for loading or 2 mg/kg for maintenance) 21 (mg/mL, concentration of reconstituted solution)
• based on a loading dose of 8 mg trastuzumab/kg body weight, or a subsequent 3-weekly dose of 6 mg trastuzumab/kg body weight:
The appropriate amount of solution should be withdrawn from the vial and added to an infusion bag containing 250 mL of 9 mg/ml (0.9%) sodium chloride solution. Do not use with glucose-containing solutions (see section 6.2). The bag should be gently inverted to mix the solution in order to avoid foaming.
Parenteral medicinal products should be inspected visually for particulate matter and discoloration prior to administration.
No incompatibilities between Zercepac and polyethylene or polypropylene bags have been observed.
Accord Healthcare Limited
Sage House, 319 Pinner Road
North Harrow, Middlesex, HA1 4HF
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angular.module('easyForms').
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I'm not really sure what it is, but it's pretty interesting stuff. I think it's mostly air and sugar. It's always a cool color, fun to eat, and tastes really sweet. However, you soon discover it's much smaller than it appears as it suddenly dissolves to nothingness in your mouth.
Let's review: Looks good and tastes good, but quickly vanishes.
Do we have a cotton candy faith? One that looks pretty when times are good, but rapidly fades when the wind and the waves kick up. A faith that is dependent upon sight rather than firmly rooted in an unwavering trust in Jesus. A faith that appears big and sweet when God acts the way we expect, but rapidly dissipates when times are tough or heaven is silent.
Jesus said, "Unless you people see signs and wonders, you simply will not believe" (John 4:48 NASB).
There's certainly nothing wrong with "signs and wonders." Our God is a miraculous God so ask Him to work wonders! But right in the middle of a carnival-like atmosphere where folks were coming from miles around to see this miracle-worker do His thing, Jesus' statement goes to the heart of true belief. To look at it another way, Jesus is asking, "What if I didn't work these signs and wonders, would you believe in Me then?" "Come one, come all – miracles galore!" and who wouldn't believe? Wind and waves…not so much.
After His resurrection, Jesus appeared to His disciples saying, "Because you have seen Me, have you believed? Blessed are they who did not see, and yet believed" (John 20:29 NASB).
Seeing Jesus clearly and true belief have much more to do with the eyes of your heart – a 20/20 vision that rests and abides in Jesus and His Word no matter what. An enduring faith that clings to a God who has revealed so much of Himself yet whose ways are not our ways and thoughts are not our thoughts (Isaiah 55:8-9). Finite creatures. Infinite God. Don't try to do the math. Put down the pencil and believe.
Sweet fellowship with Jesus doesn't have to dissolve like cotton candy. He offers a fullness of joy that is firmly tied to His very Presence. Feelings cannot always be trusted and appearances can be deceptive. So don't lose faith. Jesus will never leave you or forsake you. Trust in who He is.
"…and though you have not seen Him, you love Him, and though you do not see Him now, but believe in Him, you greatly rejoice with joy inexpressible and full of glory…" (1Peter 1:8 NASB).