Effect of Tumor Treating Fields (TTFields, 150 kHz) as Front-Line Treatment of Locally-advanced Pancreatic Adenocarcinoma Concomitant With Gemcitabine and Nab-paclitaxel (PANOVA-3)

PAST PRE-CLINICAL AND CLINICAL EXPERIENCE:

The effect of the electric fields (TTFields, TTF) has demonstrated significant activity in in
vitro and in vivo pancreatic adenocarcinoma pre-clinical models both as a single modality
treatment and in combination with chemotherapies. TTFields have been demonstrated to act
synergistically with taxanes and have been shown to be additive when combined with other
chemotherapies including gemcitabine. In addition, TTFields have shown to inhibit metastatic
spread of malignant melanoma in in vivo experiment.

In a pilot study, 40 patients with locally advanced or metastatic pancreatic adenocarcinoma
received gemcitabine together with TTFields (150 kHz) or gemcitabine and nab-paclitaxel
together with TTFields (150 kHz) applied to the abdomen until disease progression. The
combination was well tolerated and the only device-related adverse event was contact
dermatitis.

In addition, a phase III trial of Optune® (200 kHz) as monotherapy compared to active
chemotherapy in recurrent glioblastoma patients showed TTFields to be equivalent to active
chemotherapy in extending survival, associated with minimal toxicity, good quality of life,
and activity within the brain (14% response rate) (Stupp R., et al., EJC 2012). Finally, a
phase III trial of Optune® combined with maintenance temozolomide compared to maintenance
temozolomide alone has shown that combined therapy led to a significant improvement in both
progression free survival and overall survival in patients with newly diagnosed glioblastoma
without the addition of high grade toxicity and without decline in quality of life (Stupp R.,
et al., JAMA 2017).

DESCRIPTION OF THE TRIAL:

All patients included in this trial are patients with locally advanced pancreatic
adenocarcinoma. In addition, all patients must meet all eligibility criteria.

Eligible patients will be randomly assigned to one of two groups:

1. Patients receive gemcitabine and nab-paclitaxel in combination with TTFields using the
NovoTTF-100L(P) System.

2. Patients receive gemcitabine and nab-paclitaxel without TTFields.

Patients will be randomized at a 1:1 ratio. Baseline tests will be performed in patients
enrolled in both arms. If assigned to the NovoTTF-100L(P) group, the patients will be treated
continuously with the device until progression in the abdomen. On both arms, patients who
have progression outside the abdomen will switch to a second line treatment according to
local practice.

SCIENTIFIC BACKGROUND:

Electric fields exert forces on electric charges similar to the way a magnet exerts forces on
metallic particles within a magnetic field. These forces cause movement and rotation of
electrically charged biological building blocks, much like the alignment of metallic
particles seen along the lines of force radiating outwards from a magnet.

Electric fields can also cause muscles to twitch and if strong enough may heat tissues.
TTFields are alternating electric fields of low intensity. This means that they change their
direction repetitively many times a second. Since they change direction very rapidly (150
thousand times a second), they do not cause muscles to twitch, nor do they have any effects
on other electrically activated tissues in the body (brain, nerves and heart). Since the
intensities of TTFields in the body are very low, they do not cause heating.

The breakthrough finding made by Novocure was that finely tuned alternating fields of very
low intensity, now termed TTFields (Tumor Treating Fields), cause a significant slowing in
the growth of cancer cells. Due to the unique geometric shape of cancer cells when they are
multiplying, TTFields cause electrically-charged cellular components of these cells to change
their location within the dividing cell, disrupting their normal function and ultimately
leading to cell death. In addition, cancer cells also contain miniature building blocks which
act as tiny motors in moving essential parts of the cells from place to place. TTFields
interfere with the normal orientation of these tiny motors related to other cellular
components since they are electrically-charged as well. As a result of these two effects,
tumor cell division is slowed, results in cellular death or reverses after continuous
exposure to TTFields.

Other cells in the body (normal healthy tissues) are affected much less than cancer cells
since they multiply at a much slower rate if at all. In addition TTFields can be directed to
a certain part of the body, leaving sensitive areas out of their reach. Finally, the
frequency of TTFields applied to each type of cancer is specific and may not damage normally
dividing cells in healthy tissues.

In conclusion, TTFields hold the promise of serving as a brand new treatment for pancreatic
adenocarcinoma with very few side effects.

Inclusion Criteria:

1. 18 years of age and older

2. Life expectancy of ≥ 3 months

3. Histological/cytological diagnosis of de novo adenocarcinoma of the pancreas

4. Unresectable, locally advanced stage disease according to the following criteria:

- Head/uncinate process:

1. Solid tumor contact with SMA>180°

2. Solid tumor contact with the CA>180°

3. Solid tumor contact with the first jejunal SMA branch

4. Unreconstructible SMV/PV due to tumor involvement or occlusion (can be d/t
tumor or bland thrombus)

5. Contact with most proximal draining jejunal branch into SMV

- Body and tail

1. Solid tumor contact of >180° with the SMA or CA

2. Solid tumor contact with the CA and aortic involvement

3. Unreconstructible SMV/PV due to tumor involvement or occlusion (can be d/t
tumor or bland thrombus)

- No distant metastasis, including non-regional lymph node metastasis

- No borderline resectable (per Al-Hawary MM, et al., Radiology 201414)

5. ECOG score 0-2

6. Amenable and assigned by the investigator to receive therapy with gemcitabine and
nab-paclitaxel

7. Able to operate the NovoTTF-100L(P) System independently or with the help of a
caregiver

8. Signed informed consent form for the study protocol

Exclusion Criteria:

1. Prior palliative treatment (e.g. surgery, radiation) to the tumor

2. Cancer requiring anti-tumor treatment within the 5 years before inclusion, excluding
treated stage I prostate cancer, in situ cervical or uterus cancer, in situ breast
cancer and non-melanomatous skin cancer.

3. Serious co-morbidities:

1. Clinically significant (as determined by the investigator) hematological, hepatic
and renal dysfunction, defined as: Neutrophil count < 1.5 x 10^9/L and platelet
count < 100 x 10^9/L; bilirubin > 1.5 x Upper Limit of Normal (ULN); AST and/or
ALT > 2.5 x ULN; and serum creatinine > 1.5 x ULN.

2. History of significant cardiovascular disease unless the disease is well
controlled. Significant cardiac disease includes second/third degree heart block;
significant ischemic heart disease; poorly controlled hypertension; congestive
heart failure of the New York Heart Association (NYHA) Class II or worse (slight
limitation of physical activity; comfortable at rest, but ordinary activity
results in fatigue, palpitation or dyspnea).

3. History of arrhythmia that is symptomatic or requires treatment. Patients with
atrial fibrillation or flutter controlled by medication are not excluded from
participation in the trial.

4. History of cerebrovascular accident (CVA) within 6 months prior to randomization
or that is not stable.

5. Active infection or serious underlying medical condition that would impair the
ability of the patient to receive protocol therapy.

6. History of any psychiatric condition that might impair patient's ability to
understand or comply with the requirements of the study or to provide consent.

4. Concurrent anti-tumor therapy beyond gemcitabine and nab-paclitaxel

5. Implantable electronic medical devices in the torso, such as pacemakers

6. Known severe hypersensitivities to medical adhesives or hydrogel, or to one of the
chemotherapies used in this trial.

7. Pregnancy or breast-feeding (female patients with reproductive potential and their
partners must accept to use effective contraception throughout the entire study period
and for 3 months after the end of treatment). All patients who are capable of becoming
pregnant must take a pregnancy test which is negative within 72 hours before beginning
treatment. The definition of effective contraception is left up to the decision of the
investigator.

8. Unable to follow the protocol for medical, psychological, familial, geographic or
other reasons.

9. Admitted to an institution by administrative or court order.