FOLFOX +/- Ziv-Aflibercept for Esophageal and Gastric Cancer

In patients with esophagogastric cancer, mFOLFOX6 is considered standard of care. Every
person has molecules in their bloodstream called vascular endothelial growth factors (VEGFs).
These molecules help grow and sustain new blood vessels needed by the human body. Cancer
tumors hijack this mechanism because they need new blood vessels and oxygen to grow.
Ziv-aflibercept is an antibody, a "targeted therapy" called a "VEGF Trap", that "traps"
(binds) these VEGFs and prevents the cancer from using them to grow. Ziv-aflibercept has
recently been approved by the FDA for patients with treatment-resistant colorectal cancer.
Patients who received standard 5-fluoruracil based chemotherapy pus ziv-aflibercept lived
significantly longer than those patients who received standard 5-fluoruracil alone.

The study was designed to have an 80% power, at a 0.20 significance level, to detect a
difference in 6-month progression-free survival of 15%, between 65% and 50%. A one-sided log
rank test was utilized and all patients treated with at least one dose of mFOLFOX6 and
ziv-aflibercept/placebo were included in the statistical analysis.

Inclusion Criteria:

- Confirmed adenocarcinoma of esophagus, GE junction or gastric origin

- Disease is not amenable to curative resection and is unresectable, locally advanced or
metastatic

- Have not received any prior chemotherapy, investigative or biologic agents for
esophagogastric cancer except in the neoadjuvant or adjuvant setting

- Any major surgery must be completed at least 4 weeks prior to study entry, minor
procedures must be completed at least 2 weeks prior to study entry

- Vascular access device insertion should be performed at least 1 week prior to study
entry. A central line is recommended for all participants

- Willing to use adequate contraception prior to study entry, for the duration of study
participation and for 3 months after the last dose of Ziv-aflibercept/placebo

Exclusion Criteria:

- History of hypertension unless adequately controlled

- Evidence of active bleeding from primary tumor at time of study entry

- Pregnant or breastfeeding

- Squamous cell carcinoma histology

- Prior treatment for advanced or metastatic disease

- Palliative radiation to < 25% of bone marrow must have been completed 2 weeks prior to
study entry, palliative RT to > 25% must have been completed 4 weeks prior to study
entry

- Known allergy to study agents

- Known dihydropyrimidine dehydrogenase deficiency or thymidylate kinase gene
polymorphism predisposing participant to 5-FU toxicity

- History of symptomatic congestive heart failure

- Clinically significant peripheral arterial disease

- Grade 2 or higher sensory or motor neuropathy

- Serious unhealed wound, ulcers or bone fractures

- History of HIV positivity or hepatitis B or C

- History of abdominal fistula, wound dehiscence, GI perforation, intra abdominal
abscess, uncontrolled GI bleeding or diverticulitis that required hospitalization
within 6 months of study entry

- History of arterial thrombotic events

- History of CNS hemorrhage in past 6 months

- Use of warfarin

- History of prior or synchronous malignancy except if treated with curative intent more
than 3 years prior to enrollment, or adequately treated non-melanoma skin cancers,
cervical carcinoma in situ or prostatic intraepithelial neoplasia without evidence of
prostate cancer

- Uncontrolled non-malignant illness

- Uncontrolled psychiatric illness