AVASTIN (Original) SMPC

ANNEX I
SUMMARY OF PRODUCT CHARACTERISTICS
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1. NAME OF THE MEDICINAL PRODUCT
Avastin 25 mg/ml concentrate for solution for infusion.
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Each ml of concentrate contains 25 mg of bevacizumab*.

Each 4 ml vial contains 100 mg of bevacizumab.
Each 16 ml vial contains 400 mg of bevacizumab.
For dilution and other handling recommendations, see section 6.6.
*Bevacizumab is a recombinant humanised monoclonal antibody produced by DNA technology in

Chinese Hamster Ovary cells.
For the full list of excipients, see section 6.1.
3. PHARMACEUTICAL FORM
Concentrate for solution for infusion.
Clear to slightly opalescent, colourless to pale brown liquid.
4. CLINICAL PARTICULARS
4.1 Therapeutic indications
Bevacizumab in combination with fluoropyrimidine-based chemotherapy is indicated for treatment of

adult patients with metastatic carcinoma of the colon or rectum.
Bevacizumab in combination with paclitaxel is indicated for first-line treatment of adult patients with
metastatic breast cancer. For further information as to human epidermal growth factor receptor 2
(HER2) status, please refer to section 5.1.
Bevacizumab in combination with capecitabine is indicated for first-line treatment of adult patients
with metastatic breast cancer in whom treatment with other chemotherapy options including taxanes or
anthracyclines is not considered appropriate. Patients who have received taxane and anthracycline-
containing regimens in the adjuvant setting within the last 12 months should be excluded from
treatment with Avastin in combination with capecitabine. For further information as to HER2 status,
please refer to section 5.1.
Bevacizumab, in addition to platinum-based chemotherapy, is indicated for first-line treatment of adult

patients with unresectable advanced, metastatic or recurrent non-small cell lung cancer other than
predominantly squamous cell histology.
Bevacizumab, in combination with erlotinib, is indicated for first-line treatment of adult patients with
unresectable advanced, metastatic or recurrent non-squamous non-small cell lung cancer with
Epidermal Growth Factor Receptor (EGFR) activating mutations (see Section 5.1).
Bevacizumab in combination with interferon alfa-2a is indicated for first line treatment of adult
patients with advanced and/or metastatic renal cell cancer.
Bevacizumab, in combination with carboplatin and paclitaxel is indicated for the front-line treatment
of adult patients with advanced (International Federation of Gynecology and Obstetrics (FIGO) stages
III B, III C and IV) epithelial ovarian, fallopian tube, or primary peritoneal cancer. (See section 5.1).
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Bevacizumab, in combination with carboplatin and gemcitabine or in combination with carboplatin
and paclitaxel, is indicated for treatment of adult patients with first recurrence of platinum-sensitive
epithelial ovarian, fallopian tube or primary peritoneal cancer who have not received prior therapy
with bevacizumab or other VEGF inhibitors or VEGF receptor–targeted agents.
Bevacizumab in combination with paclitaxel, topotecan, or pegylated liposomal doxorubicin is

indicated for the treatment of adult patients with platinum-resistant recurrent epithelial ovarian,
fallopian tube, or primary peritoneal cancer who received no more than two prior chemotherapy
regimens and who have not received prior therapy with bevacizumab or other VEGF inhibitors or
VEGF receptor–targeted agents (see Section 5.1).
Bevacizumab, in combination with paclitaxel and cisplatin or, alternatively, paclitaxel and topotecan
in patients who cannot receive platinum therapy, is indicated for the treatment of adult patients with
persistent, recurrent, or metastatic carcinoma of the cervix (see Section 5.1).
4.2 Posology and method of administration
Avastin must be administered under the supervision of a physician experienced in the use of
antineoplastic medicinal products.
Posology
Metastatic carcinoma of the colon or rectum (mCRC)
The recommended dose of Avastin, administered as an intravenous infusion, is either 5 mg/kg or

10 mg/kg of body weight given once every 2 weeks or 7.5 mg/kg or 15 mg/kg of body weight given
once every 3 weeks.
It is recommended that treatment be continued until progression of the underlying disease or until
unacceptable toxicity.
Metastatic breast cancer (mBC)
The recommended dose of Avastin is 10 mg/kg of body weight given once every 2 weeks or 15 mg/kg
of body weight given once every 3 weeks as an intravenous infusion.
Non-small cell lung cancer (NSCLC)
First-line treatment of non-squamous NSCLC in combination with platinum-based chemotherapy
Avastin is administered in addition to platinum-based chemotherapy for up to 6 cycles of treatment

followed by Avastin as a single agent until disease progression.
The recommended dose of Avastin is 7.5 mg/kg or 15 mg/kg of body weight given once every 3
weeks as an intravenous infusion.
Clinical benefit in NSCLC patients has been demonstrated with both 7.5 mg/kg and 15 mg/kg doses
(see section 5.1).
First-line treatment of non-squamous NSCLC with EGFR activating mutations in combination with
erlotinib
EGFR mutation testing should be performed prior to initiation of treatment with the combination of
Avastin and erlotinib. It is important that a well-validated and robust methodology is chosen to avoid
false negative or false positive determinations.
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The recommended dose of Avastin when used in addition to erlotinib is 15 mg/kg of body weight
given once every 3 weeks as an intravenous infusion.
It is recommended that the treatment with Avastin in addition to erlotinib is continued until disease
progression.
For the posology and method of administration of erlotinib, please refer to the full erlotinib prescribing
information.
Advanced and/or metastatic renal cell cancer (mRCC)
The recommended dose of Avastin is 10 mg/kg of body weight given once every 2 weeks as an
intravenous infusion.
Epithelial ovarian, fallopian tube and primary peritoneal cancer
Front-line treatment: Avastin is administered in addition to carboplatin and paclitaxel for up to 6

cycles of treatment followed by continued use of Avastin as single agent until disease progression or
for a maximum of 15 months or until unacceptable toxicity, whichever occurs earlier.
Treatment of platinum-sensitive recurrent disease: Avastin is administered in combination with either

carboplatin and gemcitabine for 6 cycles and up to 10 cycles or in combination with carboplatin and
paclitaxel for 6 cycles and up to 8 cycles, followed by continued use of Avastin as single agent until
disease progression.The recommended dose of Avastin is 15 mg/kg of body weight given once every 3
weeks as an intravenous infusion.
Treatment of platinum-resistant recurrent disease: Avastin is administered in combination with one of

the following agents – paclitaxel, topotecan (given weekly) or pegylated liposomal doxorubicin. The
recommended dose of Avastin is 10 mg/kg of body weight given once every 2 weeks as an
intravenous infusion. When Avastin is administered in combination with topotecan (given on days 1-5,
every 3 weeks), the recommended dose of Avastin is 15 mg/kg of body weight given once every 3
weeks as an intravenous infusion. It is recommended that treatment be continued until disease
progression or unacceptable toxicity (see section 5.1, study MO22224).
Cervical Cancer
Avastin is administered in combination with one of the following chemotherapy regimens: paclitaxel
and cisplatin or paclitaxel and topotecan.
unacceptable toxicity (see section 5.1).
Special populations
Elderly patients: No dose adjustment is required in the patients ≥ 65 years of age.
Patients with renal impairment: The safety and efficacy have not been studied in patients with renal
impairment (see section 5.2).
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Patients with hepatic impairment: The safety and efficacy have not been studied in patients with
hepatic impairment (see section 5.2).
Paediatric population
The safety and efficacy of bevacizumab in children aged less than 18 years old have not been
established. Currently available data are described in sections 4.8, 5.1 and 5.2 but no recommendation
on a posology can be made.
There is no relevant use of bevacizumab in the paediatric population in the indications for treatment of
cancers of the colon, rectum, breast, lung, ovarian, fallopian tube, peritoneum, cervix and kidney.
Method of administration
The initial dose should be delivered over 90 minutes as an intravenous infusion. If the first infusion is
well tolerated, the second infusion may be administered over 60 minutes. If the 60-minute infusion is
well tolerated, all subsequent infusions may be administered over 30 minutes.
It should not be administered as an intravenous push or bolus.
Dose reduction for adverse reactions is not recommended. If indicated, therapy should either be
permanently discontinued or temporarily suspended as described in section 4.4.
Precautions to be taken before handling or administering the medicinal product
For instructions on dilution of the medicinal product before administration, see section 6.6. Avastin
infusions should not be administered or mixed with glucose solutions. This medicinal product must
not be mixed with other medicinal products except those mentioned in section 6.6.
4.3 Contraindications
• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
• Hypersensitivity to Chinese Hamster Ovary (CHO) cell products or other recombinant human
or humanised antibodies.
• Pregnancy (see section 4.6).
4.4 Special warnings and precautions for use
Traceability
In order to improve the traceability of biological medicinal products, the trade name and the batch
number of the administered product should be clearly recorded (or stated) in the patient file.
Gastrointestinal (GI) perforations and Fistulae (see section 4.8)

Patients may be at an increased risk for the development of gastrointestinal perforation and gall
bladder perforation when treated with Avastin. Intra-abdominal inflammatory process may be a risk
factor for gastrointestinal perforations in patients with metastatic carcinoma of the colon or rectum,
therefore, caution should be exercised when treating these patients. Prior radiation is a risk factor for
GI perforation in patients treated for persistent, recurrent or metastatic cervical cancer with Avastin
and all patients with GI perforation had a history of prior radiation. Therapy should be permanently
discontinued in patients who develop gastrointestinal perforation.
GI-vaginal Fistulae in study GOG-0240

Patients treated for persistent, recurrent, or metastatic cervical cancer with Avastin are at increased
risk of fistulae between the vagina and any part of the GI tract (Gastrointestinal-vaginal fistulae). Prior
radiation is a major risk factor for the development of GI-vaginal fistulae and all patients with GI-
vaginal fistulae had a history of prior radiation. Recurrence of cancer within the field of prior radiation
is an additional important risk factor for the development of GI-vaginal fistulae.
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Non-GI Fistulae (see section 4.8)
Patients may be at increased risk for the development of fistulae when treated with Avastin.
Permanently discontinue Avastin in patients with tracheoesophageal (TE) fistula or any Grade 4 fistula
[US National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE v.3)].
Limited information is available on the continued use of Avastin in patients with other fistulae.
In cases of internal fistula not arising in the gastrointestinal tract, discontinuation of Avastin should be
considered.
Wound healing complications (see section 4.8)

Avastin may adversely affect the wound healing process. Serious wound healing complications,
including anastomotic complications, with a fatal outcome have been reported. Therapy should not be
initiated for at least 28 days following major surgery or until the surgical wound is fully healed. In
patients who experienced wound healing complications during therapy, treatment should be withheld
until the wound is fully healed. Therapy should be withheld for elective surgery.
Necrotising fasciitis, including fatal cases, has rarely been reported in patients treated with Avastin.
This condition is usually secondary to wound healing complications, gastrointestinal perforation or
fistula formation. Avastin therapy should be discontinued in patients who develop necrotising fasciitis,
and appropriate treatment should be promptly initiated.
Hypertension (see section 4.8)

An increased incidence of hypertension was observed in Avastin-treated patients. Clinical safety data
suggest that the incidence of hypertension is likely to be dose-dependent. Pre-existing hypertension
should be adequately controlled before starting Avastin treatment. There is no information on the
effect of Avastin in patients with uncontrolled hypertension at the time of initiating therapy.
Monitoring of blood pressure is generally recommended during therapy.
In most cases hypertension was controlled adequately using standard antihypertensive treatment
appropriate for the individual situation of the affected patient. The use of diuretics to manage
hypertension is not advised in patients who receive a cisplatin-based chemotherapy regimen. Avastin
should be permanently discontinued if medically significant hypertension cannot be adequately
controlled with antihypertensive therapy, or if the patient develops hypertensive crisis or hypertensive
encephalopathy.
Posterior Reversible Encephalopathy Syndrome (PRES) (see section 4.8)

There have been rare reports of Avastin-treated patients developing signs and symptoms that are
consistent with PRES, a rare neurologic disorder, which can present with the following signs and
symptoms among others: seizures, headache, altered mental status, visual disturbance, or cortical
blindness, with or without associated hypertension. A diagnosis of PRES requires confirmation by
brain imaging, preferably magnetic resonance imaging (MRI). In patients developing PRES, treatment
of specific symptoms including control of hypertension is recommended along with discontinuation of
Avastin. The safety of reinitiating Avastin therapy in patients previously experiencing PRES is not
known.
Proteinuria (see section 4.8)

Patients with a history of hypertension may be at increased risk for the development of proteinuria
when treated with Avastin. There is evidence suggesting that all Grade (US National Cancer Institute-
Common Terminology Criteria for Adverse Events [NCI-CTCAE v.3]) proteinuria may be related to
the dose. Monitoring of proteinuria by dipstick urinalysis is recommended prior to starting and during
therapy. Grade 4 proteinuria (nephrotic syndrome) was seen in up to 1.4% of patients treated with
Avastin. Therapy should be permanently discontinued in patients who develop nephrotic syndrome
(NCI-CTCAE v.3).
Arterial thromboembolism (see section 4.8)

In clinical trials, the incidence of arterial thromboembolic reactions including cerebrovascular
accidents (CVAs), transient ischaemic attacks (TIAs) and myocardial infarctions (MIs) was higher in
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patients receiving Avastin in combination with chemotherapy compared to those who received
chemotherapy alone.
Patients receiving Avastin plus chemotherapy, with a history of arterial thromboembolism, diabetes or
age greater than 65 years have an increased risk of developing arterial thromboembolic reactions
during therapy. Caution should be taken when treating these patients with Avastin.
Therapy should be permanently discontinued in patients who develop arterial thromboembolic

reactions.
Venous thromboembolism (see section 4.8)

Patients may be at risk of developing venous thromboembolic reactions, including pulmonary
embolism under Avastin treatment.
Patients treated for persistent, recurrent, or metastatic cervical cancer with Avastin in combination
with paclitaxel and cisplatin may be at increased risk of venous thromboembolic events.
Avastin should be discontinued in patients with life-threatening (Grade 4) thromboembolic reactions,
including pulmonary embolism (NCI-CTCAE v.3). Patients with thromboembolic reactions ≤ Grade 3
need to be closely monitored (NCI-CTCAE v.3).
Haemorrhage
Patients treated with Avastin have an increased risk of haemorrhage, especially tumour-associated
haemorrhage. Avastin should be discontinued permanently in patients who experience Grade 3 or 4
bleeding during Avastin therapy (NCI-CTCAE v.3) (see section 4.8).
Patients with untreated CNS metastases were routinely excluded from clinical trials with Avastin,
based on imaging procedures or signs and symptoms. Therefore, the risk of CNS haemorrhage in such
patients has not been prospectively evaluated in randomised clinical trials (see section 4.8). Patients
should be monitored for signs and symptoms of CNS bleeding, and Avastin treatment discontinued in
cases of intracranial bleeding.
There is no information on the safety profile of Avastin in patients with congenital bleeding diathesis,
acquired coagulopathy or in patients receiving full dose of anticoagulants for the treatment of
thromboembolism prior to starting Avastin treatment, as such patients were excluded from clinical
trials. Therefore, caution should be exercised before initiating therapy in these patients. However,
patients who developed venous thrombosis while receiving therapy did not appear to have an
increased rate of Grade 3 or above bleeding when treated with a full dose of warfarin and Avastin
concomitantly (NCI-CTCAE v.3).
Pulmonary haemorrhage/haemoptysis
Patients with non-small cell lung cancer treated with Avastin may be at risk of serious, and in some
cases fatal, pulmonary haemorrhage/haemoptysis. Patients with recent pulmonary haemorrhage/
haemoptysis (> 2.5 ml of red blood) should not be treated with Avastin.
Aneurysms and artery dissections

The use of VEGF pathway inhibitors in patients with or without hypertension may promote the
formation of aneurysms and/or artery dissections. Before initiating Avastin, this risk should be
carefully considered in patients with risk factors such as hypertension or history of aneurysm.
Congestive heart failure (CHF) (see section 4.8)

Reactions consistent with CHF were reported in clinical trials. The findings ranged from
asymptomatic declines in left ventricular ejection fraction to symptomatic CHF, requiring treatment or
hospitalisation. Caution should be exercised when treating patients with clinically significant
cardiovascular disease such as pre-existing coronary artery disease, or congestive heart failure with
Avastin.
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Most of the patients who experienced CHF had metastatic breast cancer and had received previous
treatment with anthracyclines, prior radiotherapy to the left chest wall or other risk factors for CHF
were present.
In patients in AVF3694g who received treatment with anthracyclines and who had not received
anthracyclines before, no increased incidence of all Grade CHF was observed in the anthracycline +
bevacizumab group compared to the treatment with anthracyclines only. CHF Grade 3 or higher
reactions were somewhat more frequent among patients receiving bevacizumab in combination with
chemotherapy than in patients receiving chemotherapy alone. This is consistent with results in patients
in other studies of metastatic breast cancer who did not receive concurrent anthracycline treatment
(NCI-CTCAE v.3) (see section 4.8).
Neutropenia and infections (see section 4.8)

Increased rates of severe neutropenia, febrile neutropenia, or infection with or without severe
neutropenia (including some fatalities) have been observed in patients treated with some myelotoxic
chemotherapy regimens plus Avastin in comparison to chemotherapy alone. This has mainly been seen
in combination with platinum- or taxane-based therapies in the treatment of NSCLC, mBC, and in
combination with paclitaxel and topotecan in persistent, recurrent, or metastatic cervical cancer.
Hypersensitivity reactions/infusion reactions (see section 4.8)

Patients may be at risk of developing infusion/hypersensitivity reactions. Close observation of the
patient during and following the administration of bevacizumab is recommended as expected for any
infusion of a therapeutic humanised monoclonal antibody. If a reaction occurs, the infusion should be
discontinued and appropriate medical therapies should be administered. A systematic premedication is
not warranted.
Osteonecrosis of the jaw (ONJ) (see section 4.8)

Cases of ONJ have been reported in cancer patients treated with Avastin, the majority of whom had
received prior or concomitant treatment with intravenous bisphosphonates, for which ONJ is an
identified risk. Caution should be exercised when Avastin and intravenous bisphosphonates are
administered simultaneously or sequentially.
Invasive dental procedures are also an identified risk factor. A dental examination and appropriate
preventive dentistry should be considered prior to starting the treatment with Avastin. In patients who
have previously received or are receiving intravenous bisphosphonates invasive dental procedures
should be avoided, if possible.
Intravitreal use
Avastin is not formulated for intravitreal use.
Eye disorders
Individual cases and clusters of serious ocular adverse reactions have been reported following
unapproved intravitreal use of Avastin compounded from vials approved for intravenous
administration in cancer patients. These reactions included infectious endophthalmitis, intraocular
inflammation such as sterile endophthalmitis, uveitis and vitritis, retinal detachment, retinal pigment
epithelial tear, intraocular pressure increased, intraocular haemorrhage such as vitreous haemorrhage
or retinal haemorrhage and conjunctival haemorrhage. Some of these reactions have resulted in
various degrees of visual loss, including permanent blindness.
Systemic effects following intravitreal use

A reduction of circulating VEGF concentration has been demonstrated following intravitreal anti-
VEGF therapy. Systemic adverse reactions including non-ocular haemorrhages and arterial
thromboembolic reactions have been reported following intravitreal injection of VEGF inhibitors.
Ovarian failure/fertility
Avastin may impair female fertility (see sections 4.6 and 4.8). Therefore fertility preservation
strategies should be discussed with women of child-bearing potential prior to starting treatment with
Avastin.
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4.5 Interaction with other medicinal products and other forms of interaction
Effect of antineoplastic agents on bevacizumab pharmacokinetics

No clinically relevant interaction of co-administered chemotherapy on bevacizumab pharmacokinetics
was observed based on the results of population pharmacokinetic analyses. There were neither
statistically significant nor clinically relevant differences in bevacizumab clearance in patients
receiving Avastin monotherapy compared to patients receiving Avastin in combination with interferon
alfa-2a, erlotinib or chemotherapies (IFL, 5-FU/LV, carboplatin/paclitaxel, capecitabine, doxorubicin
or cisplatin/gemcitabine).
Effect of bevacizumab on the pharmacokinetics of other antineoplastic agents

No clinically relevant interaction of bevacizumab was observed on the pharmacokinetics of co-
administered interferon alfa 2a, erlotinib (and its active metabolite OSI-420), or the chemotherapies
irinotecan (and its active metabolite SN38), capecitabine, oxaliplatin (as determined by measurement
of free and total platinum), and cisplatin. Conclusions on the impact of bevacizumab on gemcitabine
pharmacokinetics cannot be drawn.
Combination of bevacizumab and sunitinib malate

In two clinical trials of metastatic renal cell carcinoma, microangiopathic haemolytic anaemia
(MAHA) was reported in 7 of 19 patients treated with bevacizumab (10 mg/kg every two weeks) and
sunitinib malate (50 mg daily) combination.
MAHA is a haemolytic disorder which can present with red cell fragmentation, anaemia, and
thrombocytopenia. In addition, hypertension (including hypertensive crisis), elevated creatinine, and
neurological symptoms were observed in some of these patients. All of these findings were reversible
upon discontinuation of bevacizumab and sunitinib malate (see Hypertension, Proteinuria, PRES in
section 4.4).
Combination with platinum- or taxane-based therapies (see sections 4.4 and 4.8)
Increased rates of severe neutropenia, febrile neutropenia, or infection with or without severe
neutropenia (including some fatalities) have been observed mainly in patients treated with platinum-
or taxane-based therapies in the treatment of NSCLC and mBC.
Radiotherapy
The safety and efficacy of concomitant administration of radiotherapy and Avastin has not been
established.
EGFR monoclonal antibodies in combination with bevacizumab chemotherapy regimens

No interaction studies have been performed. EGFR monoclonal antibodies should not be administered
for the treatment of mCRC in combination with bevacizumab-containing chemotherapy. Results from
the randomised phase III studies, PACCE and CAIRO-2, in patients with mCRC suggest that the use
of anti-EGFR monoclonal antibodies panitumumab and cetuximab, respectively, in combination with
bevacizumab plus chemotherapy, is associated with decreased PFS and/or OS, and with increased
toxicity compared with bevacizumab plus chemotherapy alone.
4.6 Fertility, pregnancy and lactation
Women of childbearing potential

Women of childbearing potential have to use effective contraception during (and up to 6 months after)
treatment.
Pregnancy
There are no clinical trial data on the use of Avastin in pregnant women. Studies in animals have
shown reproductive toxicity including malformations (see section 5.3). IgGs are known to cross the
placenta, and Avastin is anticipated to inhibit angiogenesis in the foetus, and thus is suspected to cause
serious birth defects when administered during pregnancy. In the post-marketing setting, cases of
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foetal abnormalities in women treated with bevacizumab alone or in combination with known
embryotoxic chemotherapeutics have been observed (see section 4.8). Avastin is contraindicated in
pregnancy (see section 4.3).
Breast-feeding
It is not known whether bevacizumab is excreted in human milk. As maternal IgG is excreted in milk
and bevacizumab could harm infant growth and development (see section 5.3), women must
discontinue breast-feeding during therapy and not breast-feed for at least six months following the last
dose of Avastin.
Fertility
Repeat dose toxicity studies in animals have shown that bevacizumab may have an adverse effect on
female fertility (see section 5.3). In a phase III trial in the adjuvant treatment of patients with colon
cancer, a substudy with premenopausal women has shown a higher incidence of new cases of ovarian
failure in the bevacizumab group compared to the control group. After discontinuation of bevacizumab
treatment, ovarian function recovered in the majority of patients. Long term effects of the treatment
with bevacizumab on fertility are unknown.
4.7 Effects on ability to drive and use machines
Avastin has no or negligible influence on the ability to drive and use machines. However, somnolence
and syncope have been reported with Avastin use (see table 1 in section 4.8). If patients are
experiencing symptoms that affect their vision or concentration, or their ability to react, they should be
advised not to drive and use machines until symptoms abate.
4.8 Undesirable effects
Summary of the safety profile
The overall safety profile of Avastin is based on data from over 5,700 patients with various
malignancies, predominantly treated with Avastin in combination with chemotherapy in clinical trials.
The most serious adverse reactions were:
• Gastrointestinal perforations (see section 4.4).

• Haemorrhage, including pulmonary haemorrhage/haemoptysis, which is more common in non-
small cell lung cancer patients (see section 4.4).
• Arterial thromboembolism (see section 4.4).
The most frequently observed adverse reactions across clinical trials in patients receiving Avastin
were hypertension, fatigue or asthenia, diarrhoea and abdominal pain.
Analyses of the clinical safety data suggest that the occurrence of hypertension and proteinuria with
Avastin therapy are likely to be dose-dependent.
Tabulated list of adverse reactions
The adverse reactions listed in this section fall into the following frequency categories: 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).
Tables 1 and 2 list adverse reactions associated with the use of Avastin in combination with different
chemotherapy regimens in multiple indications, by MedDRA system organ class.
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Table 1 provides all adverse reactions by frequency that were determined to have a causal relationship
with Avastin through:
• comparative incidences noted between clinical trial treatment arms (with at least a 10%
difference compared to the control arm for NCI-CTCAE Grade 1-5 reactions or at least a 2%
difference compared to the control arm for NCI-CTCAE Grade 3-5 reactions,
• post-authorisation safety studies,
• spontaneous reporting,
• epidemiological studies\non-interventional or observational studies,
• or through an evaluation of individual case reports .
Table 2 provides the frequency of severe adverse reactions. Severe reactions are defined as adverse
events with at least a 2% difference compared to the control arm in clinical studies for NCI-CTCAE
Grade 3-5 reactions. Table 2 also includes adverse reactions which are considered by the MAH to be
clinically significant or severe.
Post-marketing adverse reactions are included in both Tables 1 and 2, where applicable. Detailed
information about these post-marketing reactions are provided in Table 3.
Adverse reactions are added to the appropriate frequency category in the tables below according to the
highest incidence seen in any indication.
Within each frequency category, adverse reactions are presented in the order of decreasing seriousness.
Some of the adverse reactions are reactions commonly seen with chemotherapy; however, Avastin
may exacerbate these reactions when combined with chemotherapeutic agents. Examples include
palmar-plantar erythrodysaesthesia syndrome with pegylated liposomal doxorubicin or capecitabine,
peripheral sensory neuropathy with paclitaxel or oxaliplatin, nail disorders or alopecia with paclitaxel,
and paronychia with erlotinib.
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Table 1: Adverse Reactions by Frequency
System organ Very Common Common Uncommon Rare Very Rare Frequency Not
class Known
Infections and Sepsis, Necrotising

infestations Abscessb,d, fasciitis a
Cellulitis,
Infection,
Urinary tract
infection
Blood and Febrile Anaemia,
lymphatic neutropenia, Lymphopenia
system Leucopenia,
disorders Neutropeniab,
T hrombo-cytopenia
Immune system Hypersensitivity,
disorders infusion
reactionsa,b,d
Metabolism and Anorexia Dehydration
nutrition Hypomagnesaemia
disorders Hyponatraemia
Nervous system Peripheral sensory Cerebrovascular Posterior Hypertensive

disorders neuropathy b, accident, reversible encephalo-
Dysarthria, Syncope, encephalopathy a
Headache, Somnolence pathy
Dysguesia syndrome
a,b,d
Eye disorders Eye disorder,

Lacrimation
increased
Cardiac Congestive heart
disorders failureb,d,
Supraventricular
tachycardia
Vascular Hypertension b,d, T hrombo- Renal
disorders T hrombo-embolism embolism thrombotic
(venous) b,d (arterial)b,d, microangiopathya,b,
Haemorrhageb,d, Aneurysms and
Deep vein artery dissections
thrombosis
Respiratory, Dyspnoea, Pulmonary Pulmonary
thoracic and Rhinitis haemorrhage/ hypertension a ,
mediastinal Epistaxis Haemoptysisb,d, Nasal septum
disorders Cough Pulmonary perforation a
embolism,
Hypoxia,
Dysphoniaa
Gastrointestinal Rectal Gastrointestinal Gastrointestinal
disorders haemorrhage, perforation b,d, ulcer a
Stomatitis, Intestinal
Constipation, perforation,
Diarrhoea, Ileus,
Nausea, Intestinal
Vomiting, obstruction,
Abdominal pain Recto-vaginal
fistulaed,e ,
Gastrointestinal
Disorder,
Proctalgia
Hepatobiliary Gallbladder
disorders perforation a,b
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System organ Very Common Common Uncommon Rare Very Rare Frequency Not
class Known
Skin and Wound healing Palmar-plantar

subcutaneous complicationsb,d, erythro-
tissue disorders Exfoliative dysaesthesia
dermatitis, syndrome
Dry skin,
Skin discoloration
Musculoskeletal Arthralgia Fistulab,d, Osteonecrosis of
and connective Myalgia Muscular the jawa,b
tissue disorders weakness, Non-mandibular
Back pain osteonecrosisa,f
Renal and Proteinuriab,d
urinary
disorders
Reproductive Ovarian Pelvic Pain
system and failureb,c,d
breast disorders
Congenital, Foetal
familial, and abnormalitiesa,b
genetic disorder
General Asthenia, Lethargy
disorders and Fatigue,
administration Pyrexia,
site conditions Pain,
Mucosal
inflammation
Investigations Weight decreased
When events were noted as both all grade and grade 3-5 adverse drug reactions in clinical trials, the highest
frequency observed in patients has been reported. Data are unadjusted for the differential time on treatment.
a
For further information please refer to Table 3 'Adverse reactions reported in post-marketing setting.'
b
Terms represent a group of events that describe a medical concept rather than a single condition or MedDRA
(Medical Dictionary for Regulatory Activities) preferred term. This group of medical terms may involve the same
underlying pathophysiology (e.g. arterial thromboembolic reactions include cerebrovascular accident, myocardial
infarction, transient ischaemic attack and other arterial thromboembolic reactions).
c
Based on a substudy from NSABP C-08 with 295 patients
d
For additional information refer below within section "Further information on selected serious adverse reactions."
e
Recto-vaginal fistulae are the most common fistulae in the GI-vaginal fistula category.
f
Observed in pediatric population only
13
Table 2: Severe Adverse Reactions by Frequency
System organ Very Common Common Uncommon Rare Very Frequency Not
class Rare Known
Infections and Sepsis, Necrotising

infestations Cellulitis, fasciitis c
Abscess a,b,
Infection,
Urinary tract
infection
Blood and Febrile Anaemia,
lymphatic neutropenia, Lymphopenia
system Leucopenia,
disorders Neutropeniaa ,
Thrombo-
cytopenia
Immune system Hypersensitivity,
disorders infusion reactions
a,b,c
Metabolism and Dehydration

nutrition Hyponatraemia
disorders
Nervous system Peripheral Cerebrovascular Posterior
disorders sensory accident, reversible
neuropathy a Syncope, encephalo-
Somnolence, pathy
Headache syndrome a,b,c,
Hypertensive
encephalo-
pathy c
Cardiac Congestive heart
disorders failurea,b,
Supraventricular
tachycardia
Vascular Hypertensiona,b Thromboembolism Renal
disorders arteriala,b, thrombotic
Haemorrhagea,b, microangiopathy b,c,
Thromboembolism Aneurysms and
(venous)a,b artery dissections
Deep vein
thrombosis
Respiratory, Pulmonary Pulmonary
thoracic and haemorrhage/ hypertension c ,
mediastinal Haemoptysis a,b, Nasal septum
disorders Pulmonary perforation c
embolism,
Epistaxis,
Dyspnoea,
Hypoxia
Gastrointestinal Diarrhoea, Intestinal Gastrointestinal
disorders Nausea, perforation, perforation a,b,
Vomiting, Ileus, Gastrointestinal
Abdominal Intestinal ulcerc,
pain obstruction, Rectal
Recto-vaginal haemorrhage
fistulaec,d,
Gastrointestinal
disorder,
Stomatitis,
Proctalgia
14
System organ Very Common Common Uncommon Rare Very Frequency Not
class Rare Known
Hepatobiliary Gallbladder
disorders perforation b,c
Skin and Wound healing
subcutaneous complications a,b,
tissue disorders Palmar-plantar
erythrodysaesthesia
syndrome
Musculoskeletal Fistulaa,b, Osteonecrosis of
and connective Myalgia, the jawb,c
tissue disorders Arthralgia,
Muscular
weakness,
Back Pain
Renal and Proteinuriaa,b
urinary
disorders
Reproductive Pelvic pain Ovarian failurea,b
system and
breast disorders
Congenital, Foetal
familial, and abnormalities a,c
genetic disorder
General Asthenia, Pain,
disorders and Fatigue, Lethargy,
administration Mucosal
site conditions Inflammation
Table 2 provides the frequency of severe adverse reactions. Severe reactions are defined as adverse events with
at least a 2% difference compared to the control arm in clinical studies for NCI-CTCAE Grade 3-5 reactions.
Table 2 also includes adverse reactions which are considered by the MAH to be clinically significant or severe.
These clinically significant adverse reactions were reported in clinical trials but the grade 3-5 reactions did not
meet the threshold of at least a 2% difference compared to the control arm. Table 2 also includes clinically
significant adverse reactions that were observed only in the postmarketing setting, therefore, the frequency and
NCI-CTCAE grade is not known.These clinically significant reactions have therefore been included in Table 2
within the column entitled “Frequency Not Known.”
a
Terms represent a group of events that describe a medical concept rather than a single condition or MedDRA
(Medical Dictionary for Regulatory Activities) preferred term. This group of medical terms may involve the
same underlying pathophysiology (e.g. arterial thromboembolic reactions include cerebrovascular accident,
myocardial infarction, transient ischaemic attack and other arterial thromboembolic reactions).
b
For additional information refer below within section "Further information on selected serious adverse
reactions"
c
For further information please refer to Table 3 'Adverse reactions reported in post-marketing setting.'
d
Recto-vaginal fistulae are the most common fistulae in the GI-vaginal fistula category.
Description of selected serious adverse reactions
Gastrointestinal (GI) perforations and Fistulae (see section 4.4)

Avastin has been associated with serious cases of gastrointestinal perforation.
Gastrointestinal perforations have been reported in clinical trials with an incidence of less than 1% in
patients with non-squamous non-small cell lung cancer, up to 1.3% in patients with metastatic breast
cancer, up to 2.0% in patients with metastatic renal cell cancer or in patients with ovarian cancer, and
up to 2.7% (including gastrointestinal fistula and abscess) in patients with metastatic colorectal cancer.
From a clinical trial in patients with persistent, recurrent, or metastatic cervical cancer (study GOG-
0240), GI perforations (all grade) were reported in 3.2% of patients, all of whom had a history of prior
pelvic radiation.
15
The occurrence of those events varied in type and severity, ranging from free air seen on the plain
abdominal X-ray, which resolved without treatment, to intestinal perforation with abdominal abscess
and fatal outcome. In some cases underlying intra-abdominal inflammation was present, either from
gastric ulcer disease, tumour necrosis, diverticulitis, or chemotherapy-associated colitis.
Fatal outcome was reported in approximately a third of serious cases of gastrointestinal perforations,
which represents between 0.2%-1% of all Avastin treated patients.
In Avastin clinical trials, gastrointestinal fistulae (all grade) have been reported with an incidence of
up to 2% in patients with metastatic colorectal cancer and ovarian cancer, but were also reported less
commonly in patients with other types of cancer.
GI-vaginal Fistulae in study GOG-0240

In a trial of patients with persistent, recurrent or metastatic cervical cancer, the incidence of GI-vaginal
fistulae was 8.3% in Avastin-treated patients and 0.9% in control patients, all of whom had a history of
prior pelvic radiation. The frequency of GI-vaginal fistulae in the group treated with Avastin +
chemotherapy was higher in patients with recurrence within the field of prior radiation (16.7%)
compared with patients with no prior radiation and/ or no recurrence inside the field of prior radiation
(3.6%). The corresponding frequencies in the control group receiving chemotherapy alone were 1.1%
vs. 0.8%, respectively. Patients who develop GI-vaginal fistulae may also have bowel obstructions and
require surgical intervention as well as diverting ostomies.
Non-GI Fistulae (see section 4.4)

Avastin use has been associated with serious cases of fistulae including reactions resulting in death.
From a clinical trial in patients with persistent, recurrent, or metastatic cervical cancer (GOG-240),
1.8% of Avastin-treated patients and 1.4% of control patients were reported to have had non-
gastrointestinal vaginal, vesical, or female genital tract fistulae.
Uncommon (≥ 0.1% to < 1%) reports of fistulae that involve areas of the body other than the
gastrointestinal tract (e.g. bronchopleural and biliary fistulae) were observed across various indications.
Fistulae have also been reported in post-marketing experience.
Reactions were reported at various time points during treatment ranging from one week to greater than
1 year from initiation of Avastin, with most reactions occurring within the first 6 months of therapy.
Wound healing (see section 4.4)

As Avastin may adversely impact wound healing, patients who had major surgery within the last
28 days were excluded from participation in phase III clinical trials.
In clinical trials of metastatic carcinoma of the colon or rectum, there was no increased risk of post-
operative bleeding or wound healing complications observed in patients who underwent major surgery
28-60 days prior to starting Avastin. An increased incidence of post-operative bleeding or wound
healing complication occurring within 60 days of major surgery was observed if the patient was being
treated with Avastin at the time of surgery. The incidence varied between 10% (4/40) and 20% (3/15).
Serious wound healing complications, including anastomotic complications, have been reported, some
of which had a fatal outcome.
In locally recurrent and metastatic breast cancer trials, Grade 3-5 wound healing complications were
observed in up to 1.1% of patients receiving Avastin compared with up to 0.9% of patients in the
control arms (NCI-CTCAE v.3).
In clinical trials of ovarian cancer, Grade 3-5 wound healing complications were observed in up to
1.8% of patients in the bevacizumab arm versus 0.1% in the control arm (NCI-CTCAE v.3).
16
Hypertension (see section 4.4)
In clinical trials, with the exception of study JO25567, the overall incidence of hypertension (all
grades) ranged up to 42.1% in the Avastin containing arms compared with up to 14% in the control
arms. The overall incidence of NCI-CTC Grade 3 and 4 hypertension in patients receiving Avastin
ranged from 0.4% to 17.9%. Grade 4 hypertension (hypertensive crisis) occurred in up to 1.0% of
patients treated with Avastin and chemotherapy compared to up to 0.2% of patients treated with the
same chemotherapy alone.
In study JO25567, all grade hypertension was observed in 77.3% of the patients who received Avastin
in combination with erlotinib as first-line treatment for non-squamous NSCLC with EGFR activating
mutations, compared to 14.3% of patients treated with erlotinib alone. Grade 3 hypertension was
60.0% in patients treated with Avastin in combination with erlotinib compared to 11.7% in patients
treated with erlotinib alone. There were no grade 4 or 5 hypertension events.
Hypertension was generally adequately controlled with oral anti-hypertensives such as

angiotensin-converting enzyme inhibitors, diuretics and calcium-channel blockers. It rarely resulted in
discontinuation of Avastin treatment or hospitalisation.
Very rare cases of hypertensive encephalopathy have been reported, some of which were fatal.
The risk of Avastin-associated hypertension did not correlate with the patients’ baseline characteristics,
underlying disease or concomitant therapy.
Posterior Reversible Encephalopathy Syndrome (see section 4.4)

There have been rare reports of Avastin-treated patients developing signs and symptoms that are
consistent with PRES, a rare neurological disorder. Presentation may include seizures, headache,
altered mental status, visual disturbance, or cortical blindness, with or without associated hypertension.
The clinical presentation of PRES is often nonspecific, and therefore the diagnosis of PRES requires
confirmation by brain imaging, preferably MRI.
In patients developing PRES, early recognition of symptoms with prompt treatment of specific
symptoms including control of hypertension (if associated with severe uncontrolled hypertension) is
recommended in addition to discontinuation of bevacizumab therapy. Symptoms usually resolve or
improve within days after treatment discontinuation, although some patients have experienced some
neurologic sequelae. The safety of reinitiating Avastin therapy in patients previously experiencing
PRES is not known.
Across clinical trials, 8 cases of PRES have been reported. Two of the eight cases did not have
radiological confirmation via MRI.
Proteinuria (see section 4.4)

In clinical trials, proteinuria has been reported within the range of 0.7% to 54.7% of patients receiving
Avastin.
Proteinuria ranged in severity from clinically asymptomatic, transient, trace proteinuria to nephrotic
syndrome, with the great majority as Grade 1 proteinuria (NCI-CTCAE v.3). Grade 3 proteinuria was
reported in up to 10.9% of treated patients. Grade 4 proteinuria (nephrotic syndrome) was seen in up
to 1.4% of treated patients. Testing for proteinuria is recommended prior to start of Avastin therapy. In
most clinical trials urine protein levels of ≥ 2g/24 hrs led to the holding of Avastin until recovery to
< 2g/24 hrs.
Haemorrhage (see section 4.4)

In clinical trials across all indications the overall incidence of NCI-CTCAE v.3 Grade 3-5 bleeding
reactions ranged from 0.4% to 6.9% in Avastin treated patients, compared with up to 4.5% of patients
in the chemotherapy control group.
17
0240), grade 3-5 bleeding reactions have been reported in up to 8.3% of patients treated with Avastin
in combination with paclitaxel and topotecan compared with up to 4.6% of patients treated with
paclitaxel and topotecan.
The haemorrhagic reactions that have been observed in clinical trials were predominantly tumour-
associated haemorrhage (see below) and minor mucocutaneous haemorrhage (e.g. epistaxis).
Tumour-associated haemorrhage (see section 4.4)

Major or massive pulmonary haemorrhage/haemoptysis has been observed primarily in trials in
patients with non-small cell lung cancer (NSCLC). Possible risk factors include squamous cell
histology, treatment with antirheumatic/anti-inflammatory substances, treatment with anticoagulants,
prior radiotherapy, Avastin therapy, previous medical history of atherosclerosis, central tumour
location and cavitation of tumours prior to or during therapy. The only variables that showed
statistically significant correlations with bleeding were Avastin therapy and squamous cell histology.
Patients with NSCLC of known squamous cell histology or mixed cell type with predominant
squamous cell histology were excluded from subsequent phase III trials, while patients with unknown
tumour histology were included.
In patients with NSCLC excluding predominant squamous histology, all Grade reactions were seen
with a frequency of up to 9.3% when treated with Avastin plus chemotherapy compared with up to 5%
in the patients treated with chemotherapy alone. Grade 3-5 reactions have been observed in up to 2.3%
of patients treated with Avastin plus chemotherapy as compared with < 1% with chemotherapy alone
(NCI-CTCAE v.3). Major or massive pulmonary haemorrhage/haemoptysis can occur suddenly and
up to two thirds of the serious pulmonary haemorrhages resulted in a fatal outcome.
Gastrointestinal haemorrhages, including rectal bleeding and melaena have been reported in colorectal
cancer patients, and have been assessed as tumour-associated haemorrhages.
Tumour-associated haemorrhage was also seen rarely in other tumour types and locations, including
cases of central nervous system (CNS) bleeding in patients with CNS metastases (see section 4.4).
The incidence of CNS bleeding in patients with untreated CNS metastases receiving bevacizumab has
not been prospectively evaluated in randomised clinical trials. In an exploratory retrospective analysis
of data from 13 completed randomised trials in patients with various tumour types, 3 patients out of 91
(3.3%) with brain metastases experienced CNS bleeding (all Grade 4) when treated with bevacizumab,
compared to 1 case (Grade 5) out of 96 patients (1%) that were not exposed to bevacizumab. In two
subsequent studies in patients with treated brain metastases (which included around 800 patients), one
case of Grade 2 CNS haemorrhage was reported in 83 subjects treated with bevacizumab (1.2%) at the
time of interim safety analysis (NCI-CTCAE v.3).
Across all clinical trials, mucocutaneous haemorrhage has been seen in up to 50% of Avastin-treated
patients. These were most commonly NCI-CTCAE v.3 Grade 1 epistaxis that lasted less than
5 minutes, resolved without medical intervention and did not require any changes in the Avastin
treatment regimen. Clinical safety data suggest that the incidence of minor mucocutaneous
haemorrhage (e.g. epistaxis) may be dose-dependent.
There have also been less common reactions of minor mucocutaneous haemorrhage in other locations,
such as gingival bleeding or vaginal bleeding.
Thromboembolism (see section 4.4)
Arterial thromboembolism: An increased incidence of arterial thromboembolic reactions was observed

in patients treated with Avastin across indications, including cerebrovascular accidents, myocardial
infarction, transient ischaemic attacks, and other arterial thromboembolic reactions.
18
In clinical trials, the overall incidence of arterial thromboembolic reactions ranged up to 3.8% in the
Avastin containing arms compared with up to 2.1% in the chemotherapy control arms. Fatal outcome
was reported in 0.8% of patients receiving Avastin compared to 0.5% in patients receiving
chemotherapy alone. Cerebrovascular accidents (including transient ischaemic attacks) were reported
in up to 2.7% of patients treated with Avastin in combination with chemotherapy compared to up to
0.5% of patients treated with chemotherapy alone. Myocardial infarction was reported in up to 1.4% of
patients treated with Avastin in combination with chemotherapy compared to up to 0.7% of patients
treated with chemotherapy alone.
In one clinical trial evaluating Avastin in combination with 5-fluorouracil/folinic acid, AVF2192g,
patients with metastatic colorectal cancer who were not candidates for treatment with irinotecan were
included. In this trial arterial thromboembolic reactions were observed in 11% (11/100) of patients
compared to 5.8% (6/104) in the chemotherapy control group.
Venous thromboembolism: The incidence of venous thromboembolic reactions in clinical trials was
similar in patients receiving Avastin in combination with chemotherapy compared to those receiving
the control chemotherapy alone. Venous thromboembolic reactions include deep venous thrombosis,
pulmonary embolism and thrombophlebitis.
In clinical trials across indications, the overall incidence of venous thromboembolic reactions ranged
from 2.8% to 17.3% of Avastin-treated patients compared with 3.2% to 15.6% in the control arms.
Grade 3-5 (NCI-CTCAE v.3) venous thromboembolic reactions have been reported in up to 7.8% of
patients treated with chemotherapy plus bevacizumab compared with up to 4.9% in patients treated
with chemotherapy alone (across indications, excluding persistent, recurrent, or metastatic cervical
cancer).
0240), grade 3-5 venous thromboembolic events have been reported in up to 15.6% of patients treated
with Avastin in combination with paclitaxel and cisplatin compared with up to 7.0% of patients treated
with paclitaxel and cisplatin.
Patients who have experienced a venous thromboembolic reaction may be at higher risk for a
recurrence if they receive Avastin in combination with chemotherapy versus chemotherapy alone.
Congestive heart failure (CHF)

In clinical trials with Avastin, congestive heart failure (CHF) was observed in all cancer indications
studied to date, but occurred predominantly in patients with metastatic breast cancer. In four phase III
trials (AVF2119g, E2100, BO17708 and AVF3694g) in patients with metastatic breast cancer CHF
Grade 3 (NCI-CTCAE v.3) or higher was reported in up to 3.5% of patients treated with Avastin in
combination with chemotherapy compared with up to 0.9% in the control arms. For patients in study
AVF3694g who received anthracyclines concomitantly with bevacizumab, the incidences of Grade 3
or higher CHF for the respective bevacizumab and control arms were similar to those in the other
studies in metastatic breast cancer: 2.9% in the anthracycline + bevacizumab arm and 0% in the
anthracycline + placebo arm. In addition, in study AVF3694g the incidences of all Grade CHF were
similar between the anthracycline + Avastin (6.2%) and the anthracycline + placebo arms (6.0%).
Most patients who developed CHF during mBC trials showed improved symptoms and/or left
ventricular function following appropriate medical therapy.
In most clinical trials of Avastin, patients with pre-existing CHF of NYHA (New York Heart
Association) II-IV were excluded, therefore, no information is available on the risk of CHF in this
population.
Prior anthracyclines exposure and/or prior radiation to the chest wall may be possible risk factors for
the development of CHF.
19
An increased incidence of CHF has been observed in a clinical trial of patients with diffuse large B-
cell lymphoma when receiving bevacizumab with a cumulative doxorubicin dose greater than
300 mg/m2 . This phase III clinical trial compared
rituximab/cyclophosphamide/doxorubicin/vincristine/prednisone (R-CHOP) plus bevacizumab to R-
CHOP without bevacizumab. While the incidence of CHF was, in both arms, above that previously
observed for doxorubicin therapy, the rate was higher in the R-CHOP plus bevacizumab arm. These
results suggest that close clinical observation with appropriate cardiac assessments should be
considered for patients exposed to cumulative doxorubicin doses greater than 300 mg/m2 when
combined with bevacizumab.
Hypersensitivity reactions/infusion reactions (see section 4.4 and Post-marketing experience below)
In some clinical trials anaphylactic and anaphylactoid-type reactions were reported more frequently in
patients receiving Avastin in combination with chemotherapy than with chemotherapy alone. The
incidence of these reactions in some clinical trials of Avastin is common (up to 5% in bevacizumab-
treated patients).
Infections
0240), grade 3-5 infections have been reported in up to 24% of patients treated with Avastin in
combination with paclitaxel and topotecan compared with up to 13% of patients treated with paclitaxel
and topotecan.
Ovarian failure/fertility (see sections 4.4 and 4.6)

In NSABP C-08, a phase III trial of Avastin in adjuvant treatment of patients with colon cancer, the
incidence of new cases of ovarian failure, defined as amenorrhoea lasting 3 or more months, FSH level
≥ 30 mIU/mL and a negative serum β-HCG pregnancy test, has been evaluated in 295 premenopausal
women. New cases of ovarian failure were reported in 2.6% patients in the mFOLFOX-6 group
compared to 39% in the mFOLFOX-6 + bevacizumab group. After discontinuation of bevacizumab
treatment, ovarian function recovered in 86.2% of these evaluable women. Long term effects of the
treatment with bevacizumab on fertility are unknown.
Laboratory abnormalities
Decreased neutrophil count, decreased white blood cell count and presence of urine protein may be
associated with Avastin treatment.
Across clinical trials, the following Grade 3 and 4 (NCI-CTCAE v.3) laboratory abnormalities
occurred in patients treated with Avastin with at least a 2% difference compared to the corresponding
control groups: hyperglycaemia, decreased haemoglobin, hypokalaemia, hyponatraemia, decreased
white blood cell count, increased international normalised ratio (INR).
Clinical trials have shown that transient increases in serum creatinine (ranging between 1.5-1.9 times
baseline level), both with and without proteinuria, are associated with the use of Avastin. The
observed increase in serum creatinine was not associated with a higher incidence of clinical
manifestations of renal impairment in patients treated with Avastin.
Other special populations
Elderly patients
In randomised clinical trials, age > 65 years was associated with an increased risk of developing
arterial thromboembolic reactions, including cerebrovascular accidents (CVAs), transient ischaemic
attacks (TIAs) and myocardial infarctions (MIs). Other reactions with a higher frequency seen in
patients over 65 were Grade 3-4 leucopenia and thrombocytopenia (NCI-CTCAE v.3); and all Grade
neutropenia, diarrhoea, nausea, headache and fatigue as compared to those aged ≤ 65 years when
treated with Avastin (see sections 4.4 and 4.8 under Thromboembolism). In one clinical trial, the
incidence of hypertension of grade ≥ 3 was two fold higher in patients aged > 65 years than in the
younger age group (<65 years). In a study of platinum-resistant recurrent ovarian cancer patients,
alopecia, mucosal inflammation, peripheral sensory neuropathy, proteinuria and hypertension were
20
also reported and occurred at a rate at least 5% higher in the CT + BV arm for bevacizumab-treated
patients ≥ 65 years of age compared with bevacizumab-treated patients aged < 65 years.
No increase in the incidence of other reactions, including gastrointestinal perforation, wound healing
complications, congestive heart failure, and haemorrhage was observed in elderly patients (> 65 years)
receiving Avastin as compared to those aged ≤ 65 years treated with Avastin.
The safety and efficacy of Avastin in children less than 18 years old have not been established.
In study BO25041 of Avastin added to postoperative radiation therapy (RT) with concomitant and
adjuvant temozolomide in paediatric patients with newly diagnosed supratentorial, infratentorial,
cerebellar, or peduncular high-grade glioma, the safety profile was comparable with that observed in
other tumour types in adults treated with Avastin.
In study BO20924 of Avastin with current standard of care in rhabdomyosarcoma and non-
rhabdomyosarcoma soft tissue sarcoma, the safety profile of Avastin treated children was comparable
with that observed in adults treated with Avastin.
Avastin is not approved for use in patients under the age of 18 years. In published literature reports,
cases of non-mandibular osteonecrosis have been observed in patients under the age of 18 years
treated with Avastin.
21
Post-marketing experience
Table 3 Adverse reactions reported in post-marketing setting
System organ class Reactions (frequency*)

(SOC)
Infections and Necrotising fasciitis, usually secondary to wound healing

Infestations complications, gastrointestinal perforation or fistula formation (rare)
(see also section 4.4)
Immune system Hypersensitivity reactions and infusion reactions (not known); with
disorders the following possible co-manifestations: dyspnoea/difficulty
breathing, flushing/redness/rash, hypotension or hypertension, oxygen
desaturation, chest pain, rigors and nausea/vomiting (see also section
4.4 and Hypersensitivity reactions/infusion reactions above)
Nervous system Hypertensive encephalopathy (very rare) (see also section 4.4 and
disorders Hypertension in section 4.8)
Posterior Reversible Encephalopathy Syndrome (PRES), (rare) (see
also section 4.4)
Vascular disorders Renal thrombotic microangiopathy, which may be clinically

manifested as proteinuria (not known) with or without concomitant
sunitinib use. For further information on proteinuria see section 4.4
and Proteinuria in section 4.8.
Respiratory, thoracic Nasal septum perforation (not known)

and mediastinal Pulmonary hypertension (not known)
disorders
Dysphonia (common)
Gastrointestinal Gastrointestinal ulcer (not known)

disorders
Hepatobiliary Gall bladder perforation (not known)

disorders
Musculoskeletal and Cases of Osteonecrosis of the Jaw (ONJ) have been reported in
connective tissue patients treated with Avastin, most of which occurred in patients who
disorders had identified risk factors for ONJ, in particular exposure to
intravenous bisphosphonates and/or a history of dental disease
requiring invasive dental procedures (see also section 4.4)
Cases of non-mandibular osteonecrosis have been observed in Avastin

treated paediatric patients (see section 4.8, Paediatric population).
Congenital, familial, Cases of foetal abnormalities in women treated with bevacizumab

and genetic disorder alone or in combination with known embryotoxic chemotherapeutics
have been observed (see section 4.6 )
* if specified, the frequency has been derived from clinical trial data
22
Reporting of suspected adverse reactions
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 the national reporting system
listed in Appendix V.
4.9 Overdose
The highest dose tested in humans (20 mg/kg of body weight, intravenous every 2 weeks) was
associated with severe migraine in several patients.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: antineoplastic and immunomodulating agents, antineoplastic agents, other

antineoplastic agents, monoclonal antibodies, ATC code: L01X C07
Mechanism of action
Bevacizumab binds to vascular endothelial growth factor (VEGF), the key driver of vasculogenesis
and angiogenesis, and thereby inhibits the binding of VEGF to its receptors, Flt-1 (VEGFR-1) and
KDR (VEGFR-2), on the surface of endothelial cells. Neutralising the biological activity of VEGF
regresses the vascularisation of tumours, normalises remaining tumour vasculature, and inhibits the
formation of new tumour vasculature, thereby inhibiting tumour growth.
Pharmacodynamic effects
Administration of bevacizumab or its parental murine antibody to xenotransplant models of cancer in
nude mice resulted in extensive anti-tumour activity in human cancers, including colon, breast,
pancreas and prostate. Metastatic disease progression was inhibited and microvascular permeability
was reduced.
Clinical efficacy
Metastatic carcinoma of the colon or rectum (mCRC)
The safety and efficacy of the recommended dose (5 mg/kg of body weight every two weeks) in
metastatic carcinoma of the colon or rectum were studied in three randomised, active-controlled
clinical trials in combination with fluoropyrimidine-based first-line chemotherapy. Avastin was
combined with two chemotherapy regimens:
• AVF2107g: A weekly schedule of irinotecan/bolus 5-fluorouracil/folinic acid (IFL) for a total

of 4 weeks of each 6 week-cycle (Saltz regimen).
• AVF0780g: In combination with bolus 5-fluorouracil/folinic acid (5-FU/FA) for a total of 6
weeks of each 8 week-cycle (Roswell Park regimen).
• AVF2192g: In combination with bolus 5-FU/FA for a total of 6 weeks of each 8 week-cycle
(Roswell Park regimen) in patients who were not optimal candidates for first-line irinotecan
treatment.
23
Three additional studies with bevacizumab have been conducted in mCRC patients: first-line
(NO16966), second-line with no previous bevacizumab treatment (E3200), and second-line with
previous bevacizumab treatment following disease progression in first-line (ML18147). In these
studies, bevacizumab was administered at the following dosing regimens in combination with
FOLFOX-4 (5-FU/LV/oxaliplatin), XELOX (capecitabine/oxaliplatin), and
fluoropyrimidine/irinotecan and fluoropyrimidine/oxaliplatin:
• NO16966: Avastin 7.5 mg/kg of body weight every 3 weeks in combination with oral
capecitabine and intravenous oxaliplatin (XELOX) or Avastin 5 mg/kg every 2 weeks in
combination with leucovorin plus 5-fluorouracil bolus, followed by 5-fluorouracil infusion, with
intravenous oxaliplatin (FOLFOX-4).
• E3200: Avastin 10 mg/kg of body weight every 2 weeks in combination with leucovorin and
5-fluorouracil bolus, followed by 5-fluorouracil infusion, with intravenous oxaliplatin
(FOLFOX-4) in bevacizumab-naïve patients.
• ML18147: Avastin 5.0 mg/kg of body weight every 2 weeks or Avastin 7.5 mg/kg of body
weight every 3 weeks in combination with fluoropyrimidine/irinotecan or
fluoropyrimidine/oxaliplatin in patients with disease progression following first-line treatment
with bevacizumab. Use of irinotecan- or oxaliplatin-containing regimen was switched depending
on first-line usage of either oxaliplatin or irinotecan.
AVF2107g
This was a phase III randomised, double-blind, active-controlled clinical trial evaluating Avastin in
combination with IFL as first-line treatment for metastatic carcinoma of the colon or rectum.
Eight hundred and thirteen patients were randomised to receive IFL + placebo (Arm 1) or
IFL + Avastin (5 mg/kg every 2 weeks, Arm 2). A third group of 110 patients received bolus 5-FU/FA
+ Avastin (Arm 3). Enrolment in Arm 3 was discontinued, as pre-specified, once safety of Avastin
with the IFL regimen was established and considered acceptable. All treatments were continued until
disease progression. The overall mean age was 59.4 years; 56.6% of patients had an ECOG
performance status of 0, 43% had a value of 1 and 0.4% had a value of 2. 15.5% had received prior
radiotherapy and 28.4% prior chemotherapy.
The primary efficacy variable of the trial was overall survival. The addition of Avastin to IFL resulted
in statistically significant increases in overall survival, progression-free survival and overall response
rate (see Table 4). The clinical benefit, as measured by overall survival, was seen in all pre-specified
patient subgroups, including those defined by age, sex, performance status, location of primary tumour,
number of organs involved and duration of metastatic disease.
The efficacy results of Avastin in combination with IFL-chemotherapy are displayed in Table 4.
24
Table 4 Efficacy results for trial AVF2107g
AVF2107g
Arm 1 Arm 2
IFL + placebo IFL + Avastina
Number of patients 411 402
Overall survival
Median time (months) 15.6 20.3
95% CI 14.29 – 16.99 18.46 – 24.18
Hazard ratiob 0.660
(p-value = 0.00004)
Progression-free survival
Median time (months) 6.2 10.6
Hazard ratio 0.54
(p-value < 0.0001)
Overall response rate
Rate (%) 34.8 44.8
(p-value = 0.0036)
a
5 mg/kg every 2 weeks.
b
Relative to control arm.
Among the 110 patients randomised to Arm 3 (5-FU/FA + Avastin) prior to discontinuation of this
arm, the median overall survival was 18.3 months and the median progression free survival was
8.8 months.
AVF2192g
This was a phase II randomised, double-blind, active-controlled clinical trial evaluating the efficacy
and safety of Avastin in combination with 5-FU/FA as first-line treatment for metastatic colorectal
cancer in patients who were not optimal candidates for first-line irinotecan treatment. One hundred
and five patients were randomised to 5-FU/FA + placebo arm and 104 patients to 5-FU/FA + Avastin
(5 mg/kg every 2 weeks) arm. All treatments were continued until disease progression. The addition of
Avastin 5 mg/kg every two weeks to 5-FU/FA resulted in higher objective response rates, significantly
longer progression-free survival, and a trend in longer survival as compared to 5-FU/FA chemotherapy
alone.
AVF0780g
This was a phase II randomised, active-controlled, open-labelled clinical trial investigating Avastin in
combination with 5-FU/FA as first-line treatment of metastatic colorectal cancer. The median age was
64 years. 19% of the patients had received prior chemotherapy and 14% prior radiotherapy.
Seventy-one patients were randomised to receive bolus 5-FU/FA or 5-FU/FA + Avastin (5 mg/kg
every 2 weeks). A third group of 33 patients received bolus 5-FU/FA + Avastin (10 mg/kg every
2 weeks). Patients were treated until disease progression. The primary endpoints of the trial were
objective response rate and progression-free survival. The addition of Avastin 5 mg/kg every two
weeks to 5-FU/FA resulted in higher objective response rates, longer progression-free survival, and a
trend in longer survival, compared with 5-FU/FA chemotherapy alone (see Table 5). These efficacy
data are consistent with the results from trial AVF2107g.
The efficacy data from trials AVF0780g and AVF2192g investigating Avastin in combination with
5-FU/FA-chemotherapy are summarised in Table 5.
25
Table 5 Efficacy results for trials AVF0780g and AVF2192g
AVF0780g AVF2192g
5-FU/FA + 5-FU/FA + 5-FU/FA + 5-FU/FA +
5-FU/FA
Avastina Avastinb placebo Avastin
Number of patients 36 35 33 105 104
Overall survival
Median time (months) 13.6 17.7 15.2 12.9 16.6
10.35 - 13.63 -
95% CI
16.95 19.32
Hazard ratioc - 0.52 1.01 0.79
p-value 0.073 0.978 0.16
Median time (months) 5.2 9.0 7.2 5.5 9.2
Hazard ratio 0.44 0.69 0.5
p-value - 0.0049 0.217 0.0002
Rate (percent) 16.7 40.0 24.2 15.2 26
95% CI 7.0 − 33.5 24.4 − 57.8 11.7 – 42.6 9.2 - 23.9 18.1 - 35.6
p-value 0.029 0.43 0.055
Duration of response
Median time (months) NR 9.3 5.0 6.8 9.2
25–75 percentile (months) 5.5 − NR 6.1 − NR 3.8 – 7.8 5.59 - 9.17 5.88 - 13.01
a
b
c
Relative to control arm.
NR = not reached.
NO16966
This was a phase III randomised, double-blind (for bevacizumab), clinical trial investigating Avastin
7.5 mg/kg in combination with oral capecitabine and IV oxaliplatin (XELOX), administered on a 3-
weekly schedule; or Avastin 5 mg/kg in combination with leucovorin with 5-fluorouracil bolus,
followed by 5-fluorouracil infusional, with IV oxaliplatin (FOLFOX-4), administered on a 2-weekly
schedule. The trial contained two parts: an initial unblinded 2-arm part (Part I) in which patients were
randomised to two different treatment groups (XELOX and FOLFOX-4) and a subsequent 2 x 2
factorial 4-arm part (Part II) in which patients were randomised to four treatment groups (XELOX +
placebo, FOLFOX-4 + placebo, XELOX + Avastin, FOLFOX-4 + Avastin). In Part II, treatment
assignment was double-blind with respect to Avastin.
Approximately 350 patients were randomised into each of the 4 trial arms in the Part II of the trial.
26
Table 6 Treatment regimens in trial NO16966 (mCRC)
Treatment Starting dose Schedule

FOLFOX-4 Oxaliplatin 85 mg/m2 IV 2 h Oxaliplatin on day 1
or Leucovorin 2
200 mg/m IV 2 h Leucovorin on day 1 and 2
FOLFOX-4 + 5-fluorouracil IV bolus/infusion,
Avastin 5-Fluorouracil 400 mg/m2 IV bolus, each on days 1 and 2
600 mg/m2 IV 22 h
Placebo or 5 mg/kg IV 30-90 Day 1, prior to FOLFOX-4,
Avastin min every 2 weeks
XELOX Oxaliplatin 130 mg/m2 IV 2 h Oxaliplatin on day 1
or Capecitabine 2
1000 mg/m oral bid Capecitabine oral bid for 2
XELOX + weeks (followed by 1 week off
Avastin treatment)
Placebo or 7.5 mg/kg IV 30-90 Day 1, prior to XELOX, q
Avastin min 3 weeks
5-Fluorouracil: IV bolus injection immediately after leucovorin
The primary efficacy parameter of the trial was the duration of progression-free survival. In this trial,
there were two primary objectives: to show that XELOX was non-inferior to FOLFOX-4 and to show
that Avastin in combination with FOLFOX-4 or XELOX chemotherapy was superior to chemotherapy
alone. Both co-primary objectives were met:
● Non-inferiority of the XELOX-containing arms compared with the FOLFOX-4-containing arms

in the overall comparison was demonstrated in terms of progression-free survival and overall
survival in the eligible per-protocol population.
● Superiority of the Avastin-containing arms versus the chemotherapy alone arms in the overall
comparison was demonstrated in terms of progression-free survival in the ITT population
(Table 7).
Secondary PFS analyses, based on ‘on-treatment’-based response assessments, confirmed the

significantly superior clinical benefit for patients treated with Avastin (analyses shown in Table 7),
consistent with the statistically significant benefit observed in the pooled analysis.
27
Table 7 Key efficacy results for the superiority analysis (ITT population, trial NO16966)
Endpoint (months) FOLFOX-4 FOLFOX-4 P-value

or XELOX or XELOX
+ placebo + bevacizumab
(n=701) (n=699)
Primary endpoint
Median PFS** 8.0 9.4 0.0023
Hazard ratio (97.5% CI) a 0.83 (0.72–0.95)
Secondary endpoints
Median PFS (on treatment)** 7.9 10.4 < 0.0001
Hazard ratio (97.5% CI) 0.63 (0.52-0.75)
Overall response rate 49.2 % 46.5 %

(invest. assessment)**
Median overall survival* 19.9 21.2 0.0769
Hazard ratio (97.5% CI) 0.89 (0.76-1.03)
* Overall survival analysis at clinical cut-off 31 January 2007

** Primary analysis at clinical cut-off 31 January 2006
a
relative to control arm
In the FOLFOX treatment subgroup, the median PFS was 8.6 months in placebo and 9.4 months in
bevacizumab treated patients, HR = 0.89, 97.5% CI = [0.73; 1.08]; p-value = 0.1871, the corresponding
results in the XELOX treatment subgroup being 7.4 vs. 9.3 months, HR = 0.77, 97.5% CI = [0.63;
0.94]; p-value = 0.0026.
The median overall survival was 20.3 months in placebo and 21.2 months in bevacizumab treated
patients in the FOLFOX treatment subgroup, HR=0.94, 97.5% CI = [0.75; 1.16]; p-value = 0.4937, the
corresponding results in the XELOX, treatment subgroup being 19.2 vs. 21.4 months, HR = 0.84, 97.5%
CI = [0.68; 1.04]; p-value = 0.0698.
ECOG E3200
This was a phase III randomised, active-controlled, open-label trial investigating Avastin 10 mg/kg in
combination with leucovorin with 5-fluorouracil bolus and then 5-fluorouracil infusional, with IV
oxaliplatin (FOLFOX-4), administered on a 2-weekly schedule in previously-treated patients (second
line) with advanced colorectal cancer. In the chemotherapy arms, the FOLFOX-4 regimen used the
same doses and schedule as shown in Table 6 for trial NO16966.
The primary efficacy parameter of the trial was overall survival, defined as the time from
randomisation to death from any cause. Eight hundred and twenty-nine patients were randomised (292
FOLFOX-4, 293 Avastin + FOLFOX-4 and 244 Avastin monotherapy). The addition of Avastin to
FOLFOX-4 resulted in a statistically significant prolongation of survival. Statistically significant
improvements in progression-free survival and objective response rate were also observed (see
Table 8).
28
Table 8 Efficacy results for trial E3200
E3200
FOLFOX-4 FOLFOX-4 + Avastina

Overall survival
Median (months) 10.8 13.0
95% CI 10.12 – 11.86 12.09 – 14.03
b
Hazard ratio 0.751
(p-value = 0.0012)
Hazard ratio 0.518
(p-value < 0.0001)
Objective response rate
Rate 8.6% 22.2%
(p-value < 0.0001)
a
10 mg/kg every 2 weeks
b
Relative to control arm
No significant difference was observed in the duration of overall survival between patients who
received Avastin monotherapy compared to patients treated with FOLFOX-4. Progression-free
survival and objective response rate were inferior in the Avastin monotherapy arm compared to the
FOLFOX-4 arm.
ML18147
This was a Phase III randomised, controlled, open-label trial investigating Avastin 5.0 mg/kg every 2
weeks or 7.5 mg/kg every 3 weeks in combination with fluoropyrimidine-based chemotherapy versus
fluoropyrimidine-based chemotherapy alone in patients with mCRC who have progressed on a first-
line bevacizumab-containing regimen.
Patients with histologically confirmed mCRC and disease progression were randomised 1:1 within 3
months after discontinuation of bevacizumab first-line therapy to receive fluoropyrimidine/oxaliplatin-
or fluoropyrimidine/irinotecan-based chemotherapy (chemotherapy switched depending on first-line
chemotherapy) with or without bevacizumab. Treatment was given until progressive disease or
unacceptable toxicity. The primary outcome measure was overall survival defined as the time from
randomisation until death from any cause.
A total of 820 patients were randomised. The addition of bevacizumab to fluoropyrimidine-based

chemotherapy resulted in a statistically significant prolongation of survival in patients with mCRC
who have progressed on a first-line bevacizumab-containing regimen (ITT = 819) (see Table 9).
29
Table 9 Efficacy Results for Study ML18147 (ITT population)
ML18147
fluoropyrimidine/irinotecan
fluoropyrimidine/irinotecan or
or fluoropyrimidine/oxaliplatin
fluoropyrimidine/oxaliplatin
based chemotherapy
based chemotherapy
+ Avastina
Number of Patients 410 409
Overall Survival
0.81 (0.69, 0.94)
Hazard ratio (95% confidence interval)
(p-value = 0.0062)
Progression-Free Survival
0.68 (0.59, 0.78)
Hazard ratio (95% confidence interval)
(p-value < 0.0001)
Objective Response Rate (ORR)
Patients included in analysis 406 404
Rate 3.9% 5.4%
(p-value = 0.3113)
a
5.0 mg/kg every 2 weeks or 7.5 mg/kg every 3 weeks
Statistically significant improvements in progression-free survival were also observed. Objective

response rate was low in both treatment arms and the difference was not significant.
Study E3200 used a 5 mg/kg/week equivalent dose of bevacizumab in bevacizumab-naïve patients,

while study ML18147 used a 2.5 mg/kg/week equivalent dose of bevacizumab in bevacizumab-
pretreated patients. A cross-trial comparison of the efficacy and safety data is limited by differences
between these studies, most notably in patient populations, previous bevacizumab exposure and
chemotherapy regimens. Both the 5 mg/kg/week and 2.5 mg/kg/week equivalent doses of
bevacizumab provided a statistically significant benefit with regards to OS (HR 0.751 in study E3200;
HR 0.81 in study ML18147) and PFS (HR 0.518 in study E3200; HR 0.68 in study ML18147). In
terms of safety, there was a higher overall incidence of Grade 3-5 AEs in study E3200 relative to study
ML18147.
Metastatic breast cancer (mBC)
Two large Phase III trials were designed to investigate the treatment effect of Avastin in combination
with two individual chemotherapy agents, as measured by the primary endpoint of PFS. A clinically
meaningful and statistically significant improvement in PFS was observed in both trials.
Summarised below are PFS results for the individual chemotherapy agents included in the indication:
• Study E2100 (paclitaxel)

• Median PFS increase 5.6 months, HR 0.421 (p < 0.0001, 95% CI 0.343; 0.516)
• Study AVF3694g (capecitabine)
• Median PFS increase 2.9 months, HR 0.69 (p = 0.0002, 95% CI 0.56; 0.84)
Further details of each study and the results are provided below.
ECOG E2100
Trial E2100 was an open-label, randomised, active controlled, multicentre clinical trial evaluating
Avastin in combination with paclitaxel for locally recurrent or metastatic breast cancer in patients who
had not previously received chemotherapy for locally recurrent and metastatic disease. Patients were
30
randomised to paclitaxel alone (90 mg/m2 IV over 1 hour once weekly for three out of four weeks) or
in combination with Avastin (10 mg/kg IV infusion every two weeks). Prior hormonal therapy for the
treatment of metastatic disease was allowed. Adjuvant taxane therapy was allowed only if it was
completed at least 12 months prior to trial entry. Of the 722 patients in the trial, the majority of
patients had HER2-negative disease (90%), with a small number of patients with unknown (8%) or
confirmed HER2-positive status (2%), who had previously been treated with or were considered
unsuitable for trastuzumab therapy. Furthermore, 65% of patients had received adjuvant chemotherapy
including 19% prior taxanes and 49% prior anthracyclines. Patients with central nervous system
metastases, including previously treated or resected brain lesions, were excluded.
In trial E2100, patients were treated until disease progression. In situations where early
discontinuation of chemotherapy was required, treatment with Avastin as a single agent continued
until disease progression. The patient characteristics were similar across the trial arms. The primary
endpoint of this trial was progression free survival (PFS), based on trial investigators’ assessment of
disease progression. In addition, an independent review of the primary endpoint was also conducted.
The results of this trial are presented in Table 10.
Table 10 Trial E2100 efficacy results
Investigator assessment* IRF assessment

Paclitaxel Paclitaxel/ Paclitaxel Paclitaxel/
Avastin Avastin
(n=354) (n=368) (n=354) (n=368)
Median PFS (months) 5.8 11.4 5.8 11.3
HR 0.421 0.483
(95% CI) (0.343; 0.516) (0.385; 0.607)
p-value < 0.0001 < 0.0001
Response rates (for patients with measurable disease)
Investigator assessment IRF assessment
Paclitaxel Paclitaxel/ Paclitaxel Paclitaxel/
Avastin Avastin
(n=273) (n=252) (n=243) (n=229)
% pts with objective 23.4 48.0 22.2 49.8
response
p-value < 0.0001 < 0.0001
* primary analysis
Overall survival
Paclitaxel Paclitaxel/
Avastin
(n=354) (n=368)
Median OS (months) 24.8 26.5
HR 0.869
(95% CI) (0.722; 1.046)
p-value 0.1374
The clinical benefit of Avastin as measured by PFS was seen in all pre-specified subgroups tested
(including disease-free interval, number of metastatic sites, prior receipt of adjuvant chemotherapy
and oestrogen receptor (ER) status).
31
AVF3694g
Study AVF3694g was a Phase III, multicentre, randomised, placebo-controlled trial designed to
evaluate the efficacy and safety of Avastin in combination with chemotherapy compared to
chemotherapy plus placebo as first-line treatment for patients with HER2-negative metastatic or
locally recurrent breast cancer.
Chemotherapy was chosen at the investigator's discretion prior to randomisation in a 2:1 ratio to
receive either chemotherapy plus Avastin or chemotherapy plus placebo. The choices of chemotherapy
included capecitabine, taxane (protein-bound paclitaxel, docetaxel), and anthracycline-based agents
(doxorubicin/ cyclophosphamide, epirubicin/ cyclophosphamide, 5-fluorouracil/ doxorubicin/
cyclophosphamide, 5-fluorouracil/epirubicin/cyclophosphamide) given every three weeks (q3w).
Avastin or placebo was administered at a dose of 15 mg/kg q3w.
This study included a blinded treatment phase, an optional open-label post-progression phase, and a
survival follow-up phase. During the blinded treatment phase, patients received chemotherapy and
medicinal product (Avastin or placebo) every 3 weeks until disease progression, treatment-limiting
toxicity, or death. On documented disease progression, patients who entered the optional open-label
phase could receive open-label Avastin together with a wide-range of second line therapies.
Statistical analyses were performed independently for 1) patients who received capecitabine in
combination with Avastin or placebo; 2) patients who received taxane-based or anthracycline-based
chemotherapy in combination with Avastin or placebo. The primary endpoint of the study was PFS by
investigator assessment. In addition, the primary endpoint was also assessed by an independent review
committee (IRC).
The results of this study from the final protocol defined analyses for progression free survival and
response rates for the independently powered capecitabine cohort of Study AVF3694g are presented in
Table 11 Results from an exploratory overall survival analysis which include an additional 7 months
of follow-up (approximately 46% of patients had died) are also presented. The percentage of patients
who received Avastin in the open-label phase was 62.1% in the capecitabine + placebo arm and 49.9%
in the capecitabine + Avastin arm.
32
Table 11 Efficacy results for study AVF3694g: – Capecitabine a and Avastin/Placebo (Cap +
Avastin/Pl)
Progression-free survivalb
Investigator Assessment IRC Assessment
Cap + Pl Cap + Avastin Cap + Pl Cap + Avastin

(n=206) (n=409) (n=206) (n=409)
Hazard ratio vs 0.69 (0.56; 0.84) 0.68 (0.54; 0.86)

placebo arm (95% CI)
p-value 0.0002 0.0011
Response rate (for patients with measurable disease)b
Cap + Pl (n=161) Cap + Avastin (n=325)
% pts with objective 23.6 35.4

response
p-value 0.0097
Overall survivalb
HR
0.88 (0.69; 1.13)
(95% CI)
p-value (exploratory) 0.33

a
1000 mg/m2 oral twice daily for 14 days administered every 3 weeks
b
Stratified analysis included all progression and death events except those where non-protocol therapy (NPT)
was initiated prior to documented progression; data from those patients were censored at the last tumour
assessment prior to starting NPT.
An unstratified analysis of PFS (investigator assessed) was performed that did not censor for non-
protocol therapy prior to disease progression. The results of these analyses were very similar to the
primary PFS results.
Non-small cell lung cancer (NSCLC)
First-line treatment of non-squamous NSCLC in combination with platinum-based chemotherapy
The safety and efficacy of Avastin, in addition to platinum-based chemotherapy, in the first-line
treatment of patients with non-squamous non-small cell lung cancer (NSCLC), was investigated in
trials E4599 and BO17704. An overall survival benefit has been demonstrated in trial E4599 with a
15 mg/kg/q3wk dose of bevacizumab. Trial BO17704 has demonstrated that both 7.5 mg/kg/q3wk and
15 mg/kg/q3wk bevacizumab doses increase progression free survival and response rate.
E4599
E4599 was an open-label, randomised, active-controlled, multicentre clinical trial evaluating Avastin
as first-line treatment of patients with locally advanced (stage IIIb with malignant pleural effusion),
metastatic or recurrent NSCLC other than predominantly squamous cell histology.
33
Patients were randomised to platinum-based chemotherapy (paclitaxel 200 mg/m2 ) and carboplatin
AUC = 6.0, both by IV infusion (PC) on day 1 of every 3-week cycle for up to 6 cycles or PC in
combination with Avastin at a dose of 15 mg/kg IV infusion day 1 of every 3-week cycle. After
completion of six cycles of carboplatin-paclitaxel chemotherapy or upon premature discontinuation of
chemotherapy, patients on the Avastin + carboplatin–paclitaxel arm continued to receive Avastin as a
single agent every 3 weeks until disease progression. 878 patients were randomised to the two arms.
During the trial, of the patients who received trial treatment, 32.2% (136/422) of patients received
7-12 administrations of Avastin and 21.1% (89/422) of patients received 13 or more administrations of
Avastin.
The primary endpoint was duration of survival. Results are presented in Table 12.
Table 12 Efficacy results for trial E4599
Arm 1 Arm 2
Carboplatin/ Carboplatin/
Paclitaxel Paclitaxel +
Avastin
15 mg/kg q 3 weeks
Overall survival
Hazard ratio 0.80 (p=0.003)
95% CI (0.69; 0.93)
Hazard ratio 0.65 (p < 0.0001)
95% CI (0.56; 0.76)
Rate (percent) 12.9 29.0 (p < 0.0001)
In an exploratory analysis, the extent of Avastin benefit on overall survival was less pronounced in the
subgroup of patients who did not have adenocarcinoma histology.
BO17704
Trial BO17704 was a randomised, double-blind phase III trial of Avastin in addition to cisplatin and
gemcitabine versus placebo, cisplatin and gemcitabine in patients with locally advanced (stage IIIb
with supraclavicular lymph node metastases or with malignant pleural or pericardial effusion),
metastatic or recurrent non-squamous NSCLC, who had not received prior chemotherapy. The primary
endpoint was progression free survival, secondary endpoints for the trial included the duration of
overall survival.
Patients were randomised to platinum-based chemotherapy, cisplatin 80 mg/m2 intravenous infusion

on day 1 and gemcitabine 1250 mg/m2 intravenous infusion on days 1 and 8 of every 3-week cycle for
up to 6 cycles (CG) with placebo or CG with Avastin at a dose of 7.5 or 15 mg/kg IV infusion day 1 of
every 3-week cycle. In the Avastin-containing arms, patients could receive Avastin as a single-agent
every 3 weeks until disease progression or unacceptable toxicity. Trial results show that 94%
(277 / 296) of eligible patients went on to receive single agent bevacizumab at cycle 7. A high
proportion of patients (approximately 62%) went on to receive a variety of non-protocol specified anti-
cancer therapies, which may have impacted the analysis of overall survival.
34
The efficacy results are presented in Table 13.
Table 13 Efficacy results for trial BO17704
Cisplatin/Gemcitabine Cisplatin/Gemcitabine
Cisplatin/Gemcitabine + Avastin + Avastin
+ placebo 7.5 mg/kg q 3 weeks 15 mg/kg q 3 weeks
Number of patients 347 345 351
Progression-free
survival
Median (months) 6.1 6.7 6.5
(p=0.0026) (p=0.0301)
Hazard ratio 0.75 0.82
[0.62; 0.91] [0.68; 0.98]
Best overall 20.1% 34.1% 30.4%
response ratea (p < 0.0001) (p=0.0023)
a
patients with measurable disease at baseline
Overall survival
13.1 13.6 13.4
Median (months) (p=0.4203) (p=0.7613)
Hazard ratio 0.93 1.03
[0.78; 1.11] [0.86, 1.23]
First-line treatment of non-squamous NSCLC with EGFR activating mutations in combination with
erlotinib
JO25567
Study JO25567 was a randomized, open-label, multi-center Phase II study conducted in Japan to
evaluate the efficacy and safety of Avastin used in addition to erlotinib in patients with non-squamous
NSCLC with EGFR activating mutations (exon 19 deletion or exon 21 L858R mutation) who had not
received prior systemic therapy for Stage IIIB/IV or recurrent disease.
The primary endpoint was progression-free survival (PFS) based on independent review assessment.
Secondary endpoints included overall survival, response rate, disease control rate, duration of response,
and safety.
EGFR mutation status was determined for each patient prior to patient screening and 154 patients were
randomised to receive either erlotinib + Avastin (erlotinib 150 mg oral daily + Avastin [15 mg/kg IV
every 3 weeks]) or erlotinib monotherapy (150 mg oral daily) until disease progression (PD) or
unacceptable toxicity. In the absence of PD, discontinuation of one component of study treatment in
the erlotinib + Avastin arm did not lead to discontinuation of the other component of study treatment
as specified in the study protocol.
35
The efficacy results of the study are presented in Table 14.
Table 14 Efficacy results for study JO25567
Erlotinib Erlotinib + Avastin

N = 77 # N = 75 #
PFS^ (months)
Median 9.7 16.0
HR (95% CI) 0.54 (0.36; 0.79)
p-value 0.0015
Overall Response Rate
Rate (n) 63.6% (49) 69.3% (52)
p-value 0.4951
Overall Survival* (months)
Median 47.4 47.0
HR (95% CI) 0.81 (0.53; 1.23)
p-value 0.3267
# A total of 154 patients (ECOG Performance Status 0 or 1) were randomized. However two of the
randomized patients discontinued the study before receiving any study treatment
^ Blinded independent review (protocol-defined primary analysis)
* Exploratory analysis: final OS analysis at clinical cut off on 31 October 2017, approx. 59% of patients had died.
CI, confidence interval; HR, Hazard ratio from unstratified Cox regression analysis; NR, not reached.
Advanced and/or metastatic renal cell cancer (mRCC)
Avastin in combination with interferon alfa-2a for the first-line treatment of advanced and/ or
metastatic renal cell cancer (BO17705)
This was a phase III randomised double-blind trial conducted to evaluate the efficacy and safety of
Avastin in combination with interferon (IFN) alfa-2a versus IFN alfa-2a alone as first-line treatment in
mRCC. The 649 randomised patients (641 treated) had Karnofsky Performance Status (KPS) of ≥ 70%,
no CNS metastases and adequate organ function. Patients were nephrectomised for primary renal cell
carcinoma. Avastin 10 mg/kg was given every 2 weeks until disease progression. IFN alfa-2a was
given up to 52 weeks or until disease progression at a recommended starting dose of 9 MIU three
times a week, allowing a dose reduction to 3 MIU three times a week in 2 steps. Patients were
stratified according to country and Motzer score and the treatment arms were shown to be well
balanced for the prognostic factors.
The primary endpoint was overall survival, with secondary endpoints for the trial including
progression-free survival. The addition of Avastin to IFN-alpha-2a significantly increased PFS and
objective tumour response rate. These results have been confirmed through an independent
radiological review. However, the increase in the primary endpoint of overall survival by 2 months
was not significant (HR= 0.91). A high proportion of patients (approximately 63% IFN/placebo; 55%
Avastin/IFN) received a variety of non-specified post-trial anti-cancer therapies, including
antineoplastic agents, which may have impacted the analysis of overall survival.
36
The efficacy results are presented in Table 15
Table 15 Efficacy results for trial BO17705
BO17705
Placebo + IFNa Bvb + IFNa

Hazard ratio 0.63
95% CI 0.52, 0.75
(p-value < 0.0001)
Objective response rate (%) in Patients
with measurable disease
N 289 306
Response rate 12.8% 31.4%
(p-value < 0.0001)
a
Interferon alfa-2a 9 MIU 3x/week
b
Bevacizumab 10 mg/kg q 2 wk
Overall survival
Hazard ratio 0.91
95% CI 0.76, 1.10
(p-value 0.3360)
An exploratory multivariate Cox regression model using backward selection indicated that the
following baseline prognostic factors were strongly associated with survival independent of treatment:
gender, white blood cell count, platelets, body weight loss in the 6 months prior to trial entry, number
of metastatic sites, sum of longest diameter of target lesions, Motzer score. Adjustment for these
baseline factors resulted in a treatment hazard ratio of 0.78 (95% CI [0.63; 0.96], p=0.0219),
indicating a 22% reduction in the risk of death for patients in the Avastin + IFN alfa-2a arm compared
to IFN alfa-2a arm.
Ninety seven (97) patients in the IFN alfa-2a arm and 131 patients in the Avastin arm reduced the dose
of IFN alfa-2a from 9 MIU to either 6 or 3 MIU three times a week as pre-specified in the protocol.
Dose-reduction of IFN alfa-2a did not appear to affect the efficacy of the combination of Avastin and
IFN alfa-2a based on PFS event free rates over time, as shown by a sub-group analysis. The 131
patients in the Avastin + IFN alfa-2a arm who reduced and maintained the IFN alfa-2a dose at 6 or 3
MIU during the trial, exhibited at 6, 12 and 18 months PFS event free rates of 73, 52 and 21%
respectively, as compared to 61, 43 and 17% in the total population of patients receiving Avastin +
IFN alfa-2a.
AVF2938
This was a randomised, double-blind, phase II clinical trial investigating Avastin 10 mg/kg in a 2
weekly schedule with the same dose of Avastin in combination with 150 mg daily erlotinib, in patients
with metastatic clear cell RCC. A total of 104 patients were randomised to treatment in this trial, 53 to
Avastin 10 mg/kg every 2 weeks plus placebo and 51 to Avastin 10 mg/kg every 2 weeks plus
erlotinib 150 mg daily. The analysis of the primary endpoint showed no difference between the
Avastin + Placebo arm and the Avastin + Erlotinib arm (median PFS 8.5 versus 9.9 months). Seven
patients in each arm had an objective response. The addition of erlotinib to bevacizumab did not result
37
in an improvement in OS (HR = 1.764; p=0.1789), duration of objective response (6.7 vs 9.1 months)
or time to symptom progression (HR = 1.172; p=0.5076).
AVF0890
This was a randomised phase II trial conducted to compare the efficacy and safety of bevacizumab
versus placebo. A total of 116 patients were randomised to receive bevacizumab 3 mg/kg every 2
weeks (n=39), 10 mg/kg every 2 weeks; (n=37), or placebo (n=40). An interim analysis showed there
was a significant prolongation of the time to progression of disease in the 10 mg/kg group as
compared with the placebo group (hazard ratio, 2.55; p < 0.001). There was a small difference, of
borderline significance, between the time to progression of disease in the 3 mg/kg group and that in
the placebo group (hazard ratio, 1.26; p=0.053). Four patients had objective (partial) response, and all
of these had received the 10 mg/kg dose bevacizumab; the ORR for the 10 mg/kg dose was 10%.
Epithelial ovarian, fallopian tube and primary peritoneal cancer
Front-line treatment of ovarian cancer
The safety and efficacy of Avastin in the front-line treatment of patients with epithelial ovarian,
fallopian tube or primary peritoneal cancer were studied in two phase III trials (GOG-0218 and
BO17707) that evaluated the effect of the addition of Avastin to carboplatin and paclitaxel compared
to the chemotherapy regimen alone.
GOG-0218
The GOG-0218 study was a phase III multicentre, randomised, double-blind, placebo-controlled, three
arm study evaluating the effect of adding Avastin to an approved chemotherapy regimen (carboplatin
and paclitaxel) in patients with advanced ( Stages IIIB, IIIC and IV according to FIGO staging version
dated 1988) epithelial ovarian, fallopian tube or primary peritoneal cancer.
Patients who had received prior therapy with bevacizumab or prior systemic anticancer therapy for
ovarian cancer (e.g. chemotherapy, monoclonal antibody therapy, tyrosine kinase inhibitor therapy, or
hormonal therapy) or previous radiotherapy to the abdomen or pelvis were excluded from the study.
A total of 1873 patients were randomised in equal proportions to the following three arms:
• CPP arm: Five cycles of placebo (started cycle 2) in combination with carboplatin (AUC 6)
and paclitaxel (175 mg/m2 ) for 6 cycles followed by placebo alone, for a total of up to 15
months of therapy
• CPB15 arm: Five cycles of Avastin (15 mg/kg q3w started cycle 2) in combination with
carboplatin (AUC 6) and paclitaxel (175 mg/m2 ) for 6 cycles followed by placebo alone, for a
total of up to 15 months of therapy
• CPB15+ arm: Five cycles of Avastin (15 mg/kg q3w started cycle 2) in combination with
carboplatin (AUC 6) and paclitaxel (175 mg/m2 ) for 6 cycles followed by continued use of
Avastin (15 mg/kg q3w) as single agent for a total of up to 15 months of therapy.
The majority of patients included in the study were White (87% in all three arms); the median age was
60 years in CPP and CPB15 arms and 59 years in CPB15+ arm; and 29% of patients in CPP or CPB15
and 26% in CPB15+ were over 65 years of age. Overall approximately 50% of patients had a GOG PS
of 0 at baseline, 43% a GOG PS score of 1, and 7% a GOG PS score of 2. Most patients had EOC (82%
in CPP and CPB15, 85% in CPB15+) followed by PPC (16% in CPP, 15% in CPB15, 13% in CPB15+)
and FTC (1% in CPP, 3% in CPB15, 2% in CPB15+). The majority of patients had serous
adenocarcinoma histologic type (85% in CPP and CPB15, 86% in CPB15+). Overall approximately 34%
of patients were FIGO Stage III optimally debulked with gross residual disease, 40% Stage III sub-
optimally debulked, and 26% were Stage IV patients.
38
The primary endpoint was PFS based on investigator’s assessment of disease progression based on
radiological scans or CA 125 levels, or symptomatic deterioration per protocol. In addition, a
prespecified analysis of the data censoring for CA-125 progression events was conducted, as well as
an independent review of PFS as determined by radiological scans.
The trial met its primary objective of PFS improvement. Compared to patients treated with
chemotherapy (carboplatin and paclitaxel) alone in the front-line setting, patients who received
bevacizumab at a dose of 15 mg/kg q3w in combination with chemotherapy and continued to receive
bevacizumab alone (CPB15+), had a clinically meaningful and statistically significant improvement in
PFS.
In patients who only received bevacizumab in combination with chemotherapy and did not continue to
receive bevacizumab alone (CPB15), no clinically meaningful benefit in PFS was observed.
The results of this study are summarised in Table 16.
Table 16 Efficacy results from study GOG-0218
Progression-free survival 1
CPP CPB15 CPB15+
(n = 625) (n = 625) (n = 623)
Median PFS (months) 10.6 11.6 14.7
Hazard Ratio (95% CI) 2 0.89 0.70
(0.78, 1.02) (0.61, 0.81)
p-value 3, 4 0.0437 < 0.0001
Objective response Rate 5
CPP CPB15 CPB15 +
(n = 396) (n = 393) (n = 403)
% pts with objective response 63.4 66.2 66.0
p-value 0.2341 0.2041
Overall survival 6
CPP CPB15 CPB15 +
(n = 625) (n = 625) (n = 623)
Median OS (months) 40.6 38.8 43.8
Hazard Ratio (95% CI) 2 1.07 (0.91, 1.25) 0.88 (0.75, 1.04)
p-value 3 0.2197 0.0641
1
Investigator assessed GOG protocol-specified PFS analysis (neither censored for CA-125 progressions nor
censored for NPT prior to disease progression) with data cut-off date of 25 February, 2010.
2
Relative to the control arm; stratified hazard ratio.
3
One-sided log-rank p-value
4
Subject to a p-value boundary of 0.0116.
5
Patients with measurable disease at baseline.
6
Final overall survival analysis performed when 46.9% of the patients had died.
Prespecified PFS analyses were conducted, all with a cut-off date of 29 September 2009. The results
of these prespecified analyses are as follows:
• The protocol specified analysis of investigator-assessed PFS (without censoring for CA-125
progression or non-protocol therapy [NPT]) shows a stratified hazard ratio of 0.71 (95% CI:
0.61-0.83, 1-sided log-rank p-value < 0.0001) when CPB15+ is compared with CPP, with a
median PFS of 10.4 months in the CPP arm and 14.1 months in the CPB15+ arm.
39
• The primary analysis of investigator-assessed PFS (censoring for CA-125 progressions and
NPT) shows a stratified hazard ratio of 0.62 (95% CI: 0.52-0.75, 1-sided log-rank p-value
< 0.0001) when CPB15+ is compared with CPP, with a median PFS of 12.0 months in the
CPP arm and 18.2 months in the CPB15+ arm.
• The analysis of PFS as determined by the independent review committee (censoring for NPT)
shows a stratified hazard ratio of 0.62 (95% CI: 0.50-0.77, 1-sided log-rank p-value < 0.0001)
when CPB15+ is compared with CPP, with a median PFS of 13.1 in the CPP arm and 19.1
months in the CPB15+ arm.
PFS subgroup analyses by disease stage and debulking status are summarised in Table 17. These
results demonstrate robustness of the analysis of PFS as shown in Table 16.
Table 17 PFS1 results by disease stage and debulking status from study GOG-0218
Randomised patients stage III optimally debulked disease 2,3

CPP CPB15 CPB15+
(n = 219) (n = 204) (n = 216)
4
Hazard ratio (95% CI) 0.81 0.66
(0.62, 1.05) (0.50, 0.86)
Randomised patients with stage III suboptimally debulked disease3
CPP CPB15 CPB15+
(n = 253) (n = 256) (n = 242)
Hazard ratio (95% CI)4 0.93 0.78
(0.77, 1.14) (0.63, 0.96)
Randomised patients with stage IV disease
CPP CPB15 CPB15+
(n = 153) (n = 165) (n = 165)
Hazard Ratio (95% CI)4 0.90 0.64
(0.70, 1.16) (0.49, 0.82)
1
Investigator assessed GOG protocol-specified PFS analysis (neither censored for CA-125 progressions nor
censored for NPT prior to disease progression) with data cut-off date of 25 February, 2010
2
With gross residual disease.
3
3.7% of the overall randomised patient population had Stage IIIB disease.
4
Relative to the control arm.
BO17707 (ICON7)
BO17707 was a Phase III, two arm, multicentre, randomised, controlled, open-label study comparing
the effect of adding Avastin to carboplatin plus paclitaxel in patients with FIGO stage I or IIA (Grade
3 or clear cell histology only; n = 142), or FIGO stage IIB - IV (all Grades and all histological types,
n = 1386) epithelial ovarian, fallopian tube or primary peritoneal cancer following surgery (NCI-
CTCAE v.3). FIGO staging version dated 1988 was used in this trial.
Patients who had received prior therapy with bevacizumab or prior systemic anticancer therapy for
ovarian cancer (e.g. chemotherapy, monoclonal antibody therapy, tyrosine kinase inhibitor therapy, or
hormonal therapy) or previous radiotherapy to the abdomen or pelvis were excluded from the study.
A total of 1528 patients were randomised in equal proportions to the following two arms:
• CP arm: Carboplatin (AUC 6) and paclitaxel (175 mg/m2 ) for 6 cycles of 3 weeks duration
• CPB7.5+ arm: Carboplatin (AUC 6) and paclitaxel (175 mg/m2 ) for 6 cycles of 3 weeks plus
Avastin (7.5 mg/kg q3w) for up to 12 months (Avastin was started at cycle 2 of chemotherapy
if treatment was initiated within 4 weeks of surgery or at cycle 1 if treatment was initiated
more than 4 weeks after surgery).
40
The majority of patients included in the study were White (96%), the median age was 57 years in both
treatment arms, 25% of patients in each treatment arm were 65 years of age or over, and
approximately 50% of patients had an ECOG PS of 1; 7% of patients in each treatment arm had an
ECOG PS of 2. The majority of patients had EOC (87.7%) followed by PPC (6.9%) and FTC (3.7%)
or a mixture of the three origins (1.7%). Most patients were FIGO Stage III (both 68%) followed by
FIGO Stage IV (13% and 14%), FIGO Stage II (10% and 11%) and FIGO Stage I (9% and 7%). The
majority of the patients in each treatment arm (74% and 71%) had poorly differentiated (Grade 3)
primary tumours at baseline. The incidence of each histologic sub-type of EOC was similar between
the treatment arms; 69% of patients in each treatment arm had serous adenocarcinoma histologic type.
The primary endpoint was PFS as assessed by the investigator using RECIST.
chemotherapy (carboplatin and paclitaxel) alone in the front-line setting, patients who received
bevacizumab at a dose of 7.5 mg/kg q3w in combination with chemotherapy and continued to receive
bevacizumab for up to 18 cycles had a statistically significant improvement in PFS.
Table 18 Efficacy results from study BO17707 (ICON7)
CP CPB7.5+
(n = 764) (n =764)
Median PFS (months) 2 16.9 19.3
Hazard ratio [95% CI] 2 0.86 [0.75; 0.98]
(p-value = 0.0185)
Objective Response Rate 1
CP CPB7.5+
(n = 277) (n = 272)
Response rate 54.9% 64.7%
(p-value = 0.0188)
3
Overall Survival
CP CPB7.5+
(n = 764) (n = 764)
Hazard ratio [95% CI] 0.99 [0. 85; 1. 15]
(p-value = 0. 8910)
1
In patients with measurable disease at baseline.
2
Investigator assessed PFS analysis with data cut-off date of 30 November 2010.
3
Final overall survival analysis performed when 46.7% of the patients had died with data cut-off date of 31
March 2013.
The primary analysis of investigator-assessed PFS with a data cut-off date of 28 February 2010 shows
an unstratified hazard ratio of 0.79 (95% CI: 0.68-0.91, 2-sided log-rank p-value 0.0010) with a
median PFS of 16.0 months in the CP arm and 18.3 months in the CPB7.5+ arm.
PFS subgroup analyses by disease stage and debulking status are summarised in Table 19. These
results demonstrate robustness of the primary analysis of PFS as shown in Table 18.
41
Table 19 PFS1 results by disease stage and debulking status from study BO17707 (ICON7)
Randomised patients stage III optimally debulked disease 2,3

CP CPB7.5+
(n = 368) (n = 383)
Median PFS (months) 17.7 19.3
Hazard ratio (95% CI) 4 0.89
(0.74, 1.07)
Randomised patients with stage III suboptimally debulked disease3
CP CPB7.5+
(n = 154) (n = 140)
Hazard ratio (95% CI)4 0.67
(0.52, 0.87)
Randomised patients with stage IV disease
CP CPB7.5+
(n = 97) (n = 104)
Hazard Ratio (95% CI)4 0.74
(0.55, 1.01)
1
Investigator assessed PFS analysis with data cut-off date of 30 November 2010.
2
With or without gross residual disease.
3
5.8% of the overall randomised patient population had Stage IIIB disease.
4
Relative to the control arm.
Recurrent ovarian cancer
The safety and efficacy of Avastin in the treatment of recurrent epithelial ovarian, fallopian tube or
primary peritoneal cancer was studied in three phase III trials (AVF4095g , MO22224 and GOG-0213)
with different patient populations and chemotherapy regimens.
• AVF4095g evaluated the efficacy and safety of bevacizumab in combination with carboplatin
and gemcitabine, followed by bevacizumab as a single agent in patients with platinum-sensitive
recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer.
• GOG-0213 evaluated the efficacy and safety of bevacizumab in combination with carboplatin
and paclitaxel, followed by bevacizumab as a single agent in patients with platinum-sensitive
recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer.
• MO22224 evaluated the efficacy and safety of bevacizumab in combination with paclitaxel,
topotecan, or pegylated liposomal doxorubicin in patients with platinum-resistant recurrent
epithelial ovarian, fallopian tube or primary peritoneal cancer.
AVF4095g
The safety and efficacy of Avastin in the treatment of patients with platinum-sensitive, recurrent
epithelial ovarian, fallopian tube or primary peritoneal cancer, who have not received prior
chemotherapy in the recurrent setting or prior bevacizumab treatment, was studied in a phase III
randomised, double-blind, placebo-controlled trial (AVF4095g). The study compared the effect of
adding Avastin to carboplatin and gemcitabine chemotherapy and continuing Avastin as a single agent
to progression, to carboplatin and gemcitabine alone.
Only patients with histologically documented ovarian, primary peritoneal, or fallopian tube carcinoma
that had recurred > 6 months after platinum-based chemotherapy and who had not received
chemotherapy in the recurrent setting and who have not received prior therapy with bevacizumab or
other VEGF inhibitors or VEGF receptor–targeted agents were included in the study.
42
A total of 484 patients with measurable disease were randomised 1:1 to either:
• Carboplatin (AUC4, Day 1) and gemcitabine (1000 mg/m2 on Days 1 and 8) and concurrent
placebo every 3 weeks for 6 and up to 10 cycles followed by placebo (every 3 weeks) alone
until disease progression or unacceptable toxicity
• Carboplatin (AUC4, Day 1) and gemcitabine (1000 mg/m2 on Days 1 and 8) and concurrent
Avastin (15 mg/kg Day 1) every 3 weeks for 6 and up to 10 cycles followed by Avastin
(15 mg/kg every 3 weeks) alone until disease progression or unacceptable toxicity
The primary endpoint was progression-free survival based on investigator assessment using modified
RECIST 1.0. Additional endpoints included objective response, duration of response, overall survival
and safety. An independent review of the primary endpoint was also conducted.
Table 20 Efficacy results from study AVF4095g
Placebo+ C/G Avastin + C/G Placebo+ C/G Avastin + C/G
(n=242) (n=242) (n=242) (n=242)
Not censored for NPT
Hazard ratio
0.524 [0.425, 0.645] 0.480 [0.377, 0.613]
(95% CI)
p –value <0.0001 <0.0001
Censored for NPT
Hazard ratio
0.484 [0.388, 0.605] 0.451 [0.351, 0.580]
(95% CI)
p –value < 0.0001 <0.0001
Objective response rate
Placebo+ C/G Avastin + C/G Placebo+ C/G Avastin + C/G
(n = 242) (n = 242) (n = 242) (n = 242)
% pts with objective
57.4% 78.5% 53.7% 74.8%
response
p –value < 0.0001 < 0.0001
Overall survival
Placebo+ C/G Avastin + C/G
(n = 242) (n = 242)
Hazard Ratio
0.952 [0.771, 1.176]
(95% CI)
p-value 0.6479
PFS subgroup analyses depending on recurrence since last platinum therapy are summarised in
Table 21.
43
Table 21 Progression-free survival by time from last platinum therapy to recurrence
Investigator Assessment
Time from last platinum therapy Placebo + C/G Avastin + C/G
to recurrence (n = 242) (n = 242)
6 - 12 months (n=202)
Median 8.0 11.9
Hazard ratio (95% CI) 0.41 (0.29 - 0.58)
> 12 months (n=282)
Median 9.7 12.4
Hazard ratio (95% CI) 0.55 (0.41 – 0.73)
GOG-0213
GOG-0213, a phase III randomized controlled open label trial, studied the safety and efficacy of
Avastin in the treatment of patients with platinum-sensitive, recurrent epithelial ovarian, fallopian tube
or primary peritoneal cancer, who have not received prior chemotherapy in the recurrent setting. There
was no exclusion criterion for prior anti-angiogenic therapy. The study evaluated the effect of adding
Avastin to carboplatin+paclitaxel and continuing Avastin as a single agent until disease progression or
unacceptable toxicity compared to carboplatin+paclitaxel alone.
A total of 673 patients were randomized in equal proportions to the following two treatment arms:
• CP arm: Carboplatin (AUC5) and paclitaxel (175 mg/m2 IV) every 3 weeks for 6 and up to 8
cycles.
• CPB arm: Carboplatin (AUC5) and paclitaxel (175 mg/m2 IV) and concurrent Avastin (15
mg/kg) every 3 weeks for 6 and up to 8 cycles, followed by Avastin (15 mg/kg every 3 weeks)
alone until disease progression or unacceptable toxicity.
Most patients in both the CP arm (80.4%) and the CPB arm (78.9%) were White. The median age was
60.0 years in the CP arm and 59.0 years in the CPB arm. The majority of patients (CP: 64.6%; CPB:
68.8%) were in the age category < 65 years. At baseline, most patients in both treatment arms had a
GOG PS of 0 (CP: 82.4%: CPB; 80.7%) or 1 (CP: 16.7%: CPB; 18.1%). A GOG PS of 2 at baseline
was reported in 0.9% of patients in the CP arm and in 1.2% of patients in the CPB arm.“
The primary efficacy endpoint was overall survival (OS). The main secondary efficacy endpoint was
progression-free survival (PFS).Results are presented in Table 22.
44
Table 22 Efficacy results1,2 from study GOG-0213
Primary Endpoint
CP CPB
Overall Survival (OS)
(n=336) (n=337)
Hazard ratio (95% CI) (eCRF)a 0.823 [CI: 0.680, 0.996]
p-Value 0.0447
Hazard ratio (95% CI) (registration form)b 0.838 [CI: 0.693, 1.014]
p-Value 0.0683
Secondary Endpoint
CP CPB
Progression-free survival (PFS)
(n=336) (n=337)
Hazard ratio (95% CI) 0.613 [CI: 0.521, 0.721]
p-value <0.0001
1 Final Analysis 2 T umour assessments and response evaluations were determined by the investigators using the GOG
RECIST criteria (Revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45:228Y247).
a
Hazard ratio was estimated from Cox proportional hazards models stratified by the duration of platinum free-interval prior
to enrolling onto this study per eCRF (electronic case report form) and secondary surgical debulking status Yes/No
(Yes=randomized to undergo cytoreduction or randomized to not undergo cytoreduction; No= not a candidate or did not
consent to cytoreduction). b stratified by the duration of treatment free-interval prior to enrolling onto this study per the
registration form, and secondary surgical debulking status Yes/No.
The trial met its primary objective of OS improvement. Treatment with Avastin at 15 mg/kg every 3
weeks in combination with chemotherapy (carboplatin and paclitaxel) for 6 and up to 8 cycles,
followed by Avastin until disease progression or unacceptable toxicity resulted, when data were
derived from eCRF, in a clinically meaningful and statistically significant improvement in OS
compared to treatment with carboplatin and paclitaxel alone.
MO22224
Study MO22224 evaluated the efficacy and safety of bevacizumab in combination with chemotherapy
for platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer. This
study was designed as an open-label, randomized, two-arm Phase III evaluation of bevacizumab plus
chemotherapy (CT+BV) versus chemotherapy alone (CT).
A total of 361 patients were enrolled into this study and administered either chemotherapy (paclitaxel,
topotecan, or pegylated liposomal doxorubicin (PLD) alone or in combination with bevacizumab:
• CT Arm (chemotherapy alone):

• Paclitaxel 80 mg/m2 as a 1-hour IV infusion on Days 1, 8, 15, and 22 every 4 weeks.
• Topotecan 4 mg/m2 as a 30-minute IV infusion on Days 1, 8, and 15 every 4 weeks.
Alternatively, a 1.25 mg/m2 dose could be administered over 30 minutes on Days 1–5
every 3 weeks.
• PLD 40 mg/m2 as a 1 mg/min IV infusion on Day 1 only every 4 weeks. After Cycle
1, the drug could be delivered as a 1-hour infusion.
• CT+BV Arm (chemotherapy plus bevacizumab):
• The chosen chemotherapy was combined with bevacizumab 10 mg/kg IV every 2
weeks (or bevacizumab 15 mg/kg every 3 weeks if used in combination with
topotecan 1.25 mg/m2 on Days 1–5 every 3 weeks).
Eligible patients had epithelial ovarian, fallopian tube or primary peritoneal cancer that progressed
within <6 months of previous platinum therapy consisting of a minimum of 4 platinum therapy cycles.
Patients should have had a life expectancy of ≥ 12 weeks and no prior radiotherapy to the pelvis or
abdomen. Most patients were FIGO Stage IIIC or Stage IV. The majority of patients in both arms had
an ECOG Performance Status (PS) of 0 (CT: 56.4% vs. CT + BV: 61.2%). The percentage of patients
45
with an ECOG PS of 1 or ≥ 2 was 38.7% and 5.0% in the CT arm, and 29.8% and 9.0% in the
CT + BV arm. Information on race exists for 29.3% of patients and nearly all patients were white. The
median age of patients was 61.0 (range: 25−84) years. A total of 16 patients (4.4%) were > 75 years
old. The overall rates of discontinuation due to adverse events were 8.8% in the CT arm and 43.6% in
the CT + BV arm (mostly due to Grade 2-3 adverse events) and the median time to discontinuation in
the CT + BV arm was 5.2 months compared with 2.4 months in the CT arm. The rates of
discontinuation due to adverse events in the subgroup of patients > 65 years old were 8.8% in the CT
arm and 50.0% in the CT + BV arm. The HR for PFS was 0.47 (95% CI: 0.35, 0.62) and 0.45 (95%
CI: 0.31, 0.67) for the < 65 and ≥ 65 subgroups, respectively.
The primary endpoint was progression-free-survival, with secondary endpoints including objective
response rate and overall survival. Results are presented in Table 23.
Table 23 Efficacy Results from Study MO22224
Primary Endpoint
Progression-Free Survival*
CT CT+BV
(n=182) (n=179)
Hazard ratio
0.379 [0.296, 0.485]
(95% CI)
p-value <0.0001
Secondary Endpoints
Objective Response Rate**
CT CT+BV
(n=144) (n=142)
% patients with objective response 18 (12.5%) 40 (28.2%)
p –value 0.0007
Overall Survival (final analysis)***
CT CT+BV
(n=182) (n=179)
Hazard Ratio
0.870 [0.678, 1.116]
(95% CI)
p-value 0.2711
All analyses presented in this table are stratified analyses.
* Primary analysis was performed with a data cut-off date of 14 November 2011.
**Randomized Patients with Measurable Disease at Baseline.
***The final analysis of overall survival was performed when 266 deaths, which account for 73.7 % of enrolled
patients, were observed.
chemotherapy (paclitaxel, topotecan or PLD) alone in the recurrent platinum-resistant setting, patients
who received bevacizumab at a dose of 10 mg/kg every 2 weeks (or 15 mg/kg every 3 weeks if used in
combination with 1.25 mg/m2 topotecan on Days 1–5 every 3 weeks) in combination with
chemotherapy and continued to receive bevacizumab until disease progression or unacceptable
toxicity, had a statistically significant improvement in PFS. The exploratory PFS and OS analyses by
chemotherapy cohort (paclitaxel, topotecan and PLD) are summarized in Table 24.
46
Table 24: Exploratory PFS and OS analyses by chemotherapy cohort
CT CT+BV
Paclitaxel n=115
Hazard ratio (95% CI) 0.47 [0.31, 0.72]
Hazard ratio (95% CI) 0.64 [0.41, 0.99]
Topotecan n=120
Hazard ratio (95% CI) 0.28 [0.18, 0.44]
Hazard ratio (95% CI) 1.07 [0.70, 1.63]
PLD n=126
Hazard ratio (95% CI) 0.53 [0.36, 0.77]
Hazard ratio (95% CI) 0.91 [0.61, 1.35]
Cervical Cancer
GOG-0240
The efficacy and safety of Avastin in combination with chemotherapy (paclitaxel and cisplatin or
paclitaxel and topotecan) in the treatment for patients with persistent, recurrent or metastatic
carcinoma of the cervix was evaluated in study GOG-0240, a randomised, four-arm, open label, multi-
centre phase III trial.
A total of 452 patients were randomised to receive either:
• Paclitaxel 135 mg/m2 IV over 24 hours on Day 1 and cisplatin 50 mg/m2 IV on Day 2, every 3
weeks (q3w); or
Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 and cisplatin 50 mg/m2 IV on Day 2 (q3w); or
Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 and cisplatin 50 mg/m2 IV on Day 1 (q3w)
• Paclitaxel 135 mg/m2 IV over 24 hours on Day 1 and cisplatin 50 mg/m2 IV on Day 2 plus
bevacizumab 15 mg/kg IV on Day 2 (q3w); or
Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 and cisplatin 50 mg/m2 IV on Day 2 plus
bevacizumab 15 mg/kg IV on Day 2 (q3w); or
Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 and cisplatin 50 mg/m2 IV on Day 1 plus
bevacizumab 15 mg/kg IV on Day 1 (q3w)
• Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 and topotecan 0.75 mg/m2 IV over 30 minutes
on days 1-3 (q3w)
• Paclitaxel 175 mg/m2 IV over 3 hours on Day 1 and topotecan 0.75 mg/m2 IV over 30 minutes
on Days 1-3 plus bevacizumab 15 mg/kg IV on Day 1 (q3w)
Eligible patients had persistent, recurrent or metastatic squamous cell carcinoma, adenosquamous
carcinoma, or adenocarcinoma of the cervix which was not amenable to curative treatment with
surgery and/or radiation therapy and who have not received prior therapy with bevacizumab or other
VEGF inhibitors or VEGF receptor–targeted agents.
47
The median age was 46.0 years (range: 20−83) in the Chemo alone group and 48.0 years
(range: 22−85) in the Chemo+Avastin group; with 9.3% of patients in the Chemo alone group and
7.5% of patients in the Chemo+Avastin group over the age of 65 years.
Of the 452 patients randomized at baseline, the majority of patients were white (80.0% in the Chemo
alone group and 75.3% in the Chemo+Avastin group), had squamous cell carcinoma (67.1% in the
Chemo alone group and 69.6% in the Chemo+Avastin group), had persistent/recurrent disease (83.6%
in the Chemo alone group and 82.8% in the Chemo+Avastin group), had 1-2 metastatic sites (72.0%
in the Chemo alone group and 76.2% in the Chemo+Avastin group), had lymph node involvement
(50.2% in the Chemo alone group and 56.4% in the Chemo+Avastin group), and had a platinum free
interval ≥ 6 months (72.5% in the Chemo alone group and 64.4% in the Chemo+Avastin group).
The primary efficacy endpoint was overall survival. Secondary efficacy endpoints included
progression-free survival and objective response rate. Results from the primary analysis and the
follow-up analysis are presented by Avastin Treatment and by Trial Treatment in Table 25 and Table
26, respectively.
Table 25 Efficacy results from study GOG-0240 by Avastin Treatment
Chemotherapy Chemotherapy + Avastin

(n=225) (n=227)
Primary Endpoint
Overall Survival – Primary analysis 6

Median (months)1 12.9 16.8
Hazard ratio [95% CI] 0.74 [0.58, 0.94]
(p-value5 = 0.0132)
Overall Survival – Follow-up analysis 7
Median (months)1 13.3 16.8
Hazard ratio [95% CI] 0.76 [0.62, 0.94]
(p-value5,8 = 0.0126)
Secondary Endpoints
Progression-free survival – Primary analysis 6
Median PFS (months)1 6.0 8.3

Hazard ratio [95% CI] 0.66 [0.54, 0.81]
5
(p-value <0.0001)
Best Overall Response – Primary analysis 6

Responders (Response rate2) 76 (33.8 %) 103 (45.4 %)
95% CI for Response Rates3 [27.6%, 40.4%] [38.8%, 52.1%]
Difference in Response Rates 11.60%
95% CI for Difference in Response Rates 4 [2.4%, 20.8%]
p-value (Chi-squared Test) 0.0117
1
Kaplan-Meier estimates
2
Patients and percentage of patients with best overall response of confirmed CR or PR; percentage calculated on
patients with measurable disease at baseline
3
95% CI for one sample binomial using Pearson-Clopper method
4
Approximate 95% CI for difference of two rates using Hauck-Anderson method
5
log-rank test (stratified)
6
Primary analysis was performed with a data cut-off date of 12 December 2012 and is considered the final
analysis
7
Follow-up analysis was performed with a data cut-off date of 07 March 2014
8
p-value displayed for descriptive purpose only
48
Table 26 Overall survival results from study GOG-0240 by Trial Treatment
Treatment Overall survival – Primary analysis 1 Overall survival - Follow-up analysis2

Comparison Other Factor Hazard Ratio (95% CI) Hazard Ratio (95% CI)
Avastin vs. Cisplatin+ 0.72 (0.51, 1.02) 0.75 (0.55, 1.01)
No Avastin Paclitaxel (17.5 vs.14.3 months; p = 0.0609) (17.5 vs.15.0 months; p = 0.0584)
Topotecan+ 0.76 (0.55, 1.06) 0.79 (0.59, 1.07)
Paclitaxel (14.9 vs. 11.9 months; p = 0.1061) (16.2 vs. 12.0 months; p = 0.1342)
Topotecan+ Avastin 1.15 (0.82, 1.61) 1.15 (0.85, 1.56)

Paclitaxel vs. (14.9 vs. 17.5 months; p = 0.4146) (16.2 vs 17.5 months; p = 0.3769)
Cisplatin+
Paclitaxel No Avastin 1.13 (0.81, 1.57) 1.08 (0.80, 1.45)
(11.9 vs.14.3 months; p = 0.4825) (12.0 vs 15.0 months; p = 0.6267)
1
Primary analysis was performed with a data cut-off date of 12 December 2012 and is considered the final
analysis
2
Follow-up analysis was performed with a data cut-off date of 07 March 2014; all p-values are displayed for
descriptive purpose only
The European Medicines Agency has waived the obligation to submit the results of studies, in all
subsets of the paediatric population, in breast carcinoma, adenocarcinoma of the colon and rectum,
lung carcinoma (small cell and non-small cell carcinoma), kidney and renal pelvis carcinoma
(excluding nephroblastoma, nephroblastomatosis, clear cell sarcoma, mesoblastic nephroma, renal
medullary carcinoma and rhabdoid tumour of the kidney), ovarian carcinoma (excluding
rhabdomyosarcoma and germ cell tumours), fallopian tube carcinoma (excluding rhabdomyosarcoma
and germ cell tumours), peritoneal carcinoma (excluding blastomas and sarcomas) and cervix and
corpus uteri carcinoma.
High-grade glioma
Anti-tumour activity was not observed in two earlier studies among a total of 30 children aged > 3
years old with relapsed or progressive high-grade glioma when treated with bevacizumab and
irinotecan (CPT-11). There is insufficient information to determine the safety and efficacy of
bevacizumab in children with newly-diagnosed high-grade glioma.
• In a single-arm study (PBTC-022), 18 children with recurrent or progressive non-pontine

high-grade glioma (including 8 with glioblastoma [WHO Grade IV], 9 with anaplastic
astrocytoma [Grade III] and 1 with anaplastic oligodendroglioma [Grade III]) were treated
with bevacizumab (10 mg/kg) two weeks apart and then with bevacizumab in combination
with CPT-11 (125-350 mg/m²) once every two weeks until progression. There were no
objective (partial or complete) radiological responses (MacDonald criteria). Toxicity and
adverse reactions included arterial hypertension and fatigue as well as CNS ischaemia with
acute neurological deficit.
• In a retrospective single institution series, 12 consecutive (2005 to 2008) children with

relapsed or progressive high-grade glioma (3 with WHO Grade IV, 9 with Grade III) were
treated with bevacizumab (10 mg/kg) and irinotecan (125 mg/m²) every 2 weeks. There were
no complete responses and 2 partial responses (MacDonald criteria).
In a randomized phase II study (BO25041) a total of 121 patients aged ≥ 3 years to <18 years with
newly diagnosed supratentorial or infratentorial cerebellar or peduncular high-grade glioma (HGG)
were treated with post operative radiation therapy (RT) and adjuvant temozolomide (T) with and
without bevacizumab: 10 mg/kg every 2 weeks IV.
49
The study did not meet its primary endpoint of demonstrating a significant improvement of EFS
(Central Radiology Review Committee (CRRC)-assessed) when bevacizumab was added to the RT/T
arm compared with RT/T alone (HR = 1.44; 95% CI: 0.90, 2.30). These results were consistent with
those from various sensitivity analyses and in clinically relevant subgroups. The results for all
secondary endpoints (investigator assessed EFS, and ORR and OS) were consistent in showing no
improvement associated with the addition of bevacizumab to the RT/T arm compared with the RT/T
arm alone.
Addition of Avastin to RT/T did not demonstrate clinical benefit in study BO25041 in 60 evaluable
children patients with newly diagnosed supratentorial or infratentorial cerebellar or peduncular high-
grade glioma (HGG) (See section 4.2 for information on paediatric use).
Soft tissue sarcoma

In a randomized phase II study (BO20924) a total of 154 patients aged ≥ 6 months to <18 years with
newly diagnosed metastatic rhabdomyosarcoma and non-rhabdomyosarcoma soft tissue sarcoma were
treated with standard of care (Induction IVADO/IVA+/- local therapy followed by Maintenance
Vinorelbine and cyclophosphamide) with or without bevacizumab (2.5 mg/kg/week) for a total
duration of treatment of approximately 18 months. At the time of the final primary analysis, the
primary endpoint of EFS by independent central review did not show a statistically significant
difference between the two treatment arms, with HR of 0.93 (95% CI: 0.61, 1.41; p-value = 0.72).
The difference in ORR per independent central review was 18% (CI: 0.6%, 35.3%) between the two
treatment arms in the few patients who had evaluable tumor at baseline and had a confirmed response
prior to receiving any local therapy : 27/75 patients (36.0%, 95% CI: 25.2%, 47.9%) in the Chemo arm
and 34/63 patients (54.0%, 95% CI: 40.9%, 66.6%) in the Bv + Chemo arm. The secondary endpoint
of Overall Survival (OS) was not mature . Until mature OS results and safety data are available no
definitive conclusion can be drawn on the benefit/risk balance.
Addition of Avastin to standard of care did not demonstrate clinical benefit in clinical trial BO20924,
in 71 evaluable children (from age 6 months to less than 18 years old) patients with metastatic
Rhabdomyosarcoma and non-Rhabdomyosarcoma Soft Tissue Sarcoma.
(See section 4.2 for information on paediatric use).
The incidence of AEs, including Grade ≥ 3 AEs and SAEs, was similar between the two treatment
arms. No AEs leading to death occurred in either treatment arm; all deaths were attributed to disease
progression. Bevacizumab addition to multimodal standard of care treatment seemed to be tolerated in
this paediatric population.
5.2 Pharmacokinetic properties
The pharmacokinetic data for bevacizumab are available from ten clinical trials in patients with solid
tumours. In all clinical trials, bevacizumab was administered as an IV infusion. The rate of infusion
was based on tolerability, with an initial infusion duration of 90 minutes. The pharmacokinetics of
bevacizumab was linear at doses ranging from 1 to 10 mg/kg.
Distribution
The typical value for central volume (Vc) was 2.73 L and 3.28 L for female and male patients
respectively, which is in the range that has been described for IgGs and other monoclonal antibodies.
The typical value for peripheral volume (Vp ) was 1.69 L and 2.35 L for female and male patients
respectively, when bevacizumab is co-administered with anti-neoplastic agents. After correcting for
body weight, male patients had a larger Vc (+ 20%) than female patients.
Biotransformation
Assessment of bevacizumab metabolism in rabbits following a single IV dose of 125 I-bevacizumab
indicated that its metabolic profile was similar to that expected for a native IgG molecule which does
not bind VEGF. The metabolism and elimination of bevacizumab is similar to endogenous IgG i.e.
primarily via proteolytic catabolism throughout the body, including endothelial cells, and does not rely
50
primarily on elimination through the kidneys and liver. Binding of the IgG to the FcRn receptor results
in protection from cellular metabolism and the long terminal half-life.
Elimination
The value for clearance is, on average, equal to 0.188 and 0.220 L/day for female and male patients,
respectively. After correcting for body weight, male patients had a higher bevacizumab clearance
(+ 17%) than females. According to the two-compartmental model, the elimination half-life is 18 days
for a typical female patient and 20 days for a typical male patient.
Low albumin and high tumour burden are generally indicative of disease severity. Bevacizumab
clearance was approximately 30% faster in patients with low levels of serum albumin and 7% faster in
subjects with higher tumour burden when compared with a typical patient with median values of
albumin and tumour burden.
Pharmacokinetics in special populations

The population pharmacokinetics were analysed in adult and pediatric patients to evaluate the effects
of demographic characteristics. In adults, the results showed no significant difference in the
pharmacokinetics of bevacizumab in relation to age.
Renal impairment
No trials have been conducted to investigate the pharmacokinetics of bevacizumab in renally impaired
patients since the kidneys are not a major organ for bevacizumab metabolism or excretion.
Hepatic impairment
No trials have been conducted to investigate the pharmacokinetics of bevacizumab in patients with
hepatic impairment since the liver is not a major organ for bevacizumab metabolism or excretion.
The pharmacokinetics of bevacizumab were evaluated in 152 children, adolescents and young adults
(7 months to 21 years, 5.9 to 125 kg) across 4 clinical studies using a population pharmacokinetic
model. The pharmacokinetic results show that the clearance and volume of distribution of
bevacizumab were comparable between paediatric and young adult patients when normalised by body
weight, with exposure trending lower as body weight decreased. Age was not associated with the
pharmacokinetics of bevacizumab when body weight was taken into account.
The pharmacokinetics of bevacizumab was well characterized by the paediatric population PK model
for 70 patients in Study BO20924 ((1.4 to 17.6 years; 11.6 to 77.5 kg) and 59 patients in Study
BO25041 (1 to 17 years; 11.2 to 82.3 kg). In Study BO20924, bevacizumab exposure was generally
lower compared to a typical adult patient at the same dose. In Study BO25041, bevacizumab exposure
was similar compared to a typical adult at the same dose. In both studies, bevacizumb exposure
trended lower as body weight decreased.
5.3 Preclinical safety data
In studies of up to 26 weeks duration in cynomolgus monkeys, physeal dysplasia was observed in

young animals with open growth plates, at bevacizumab average serum concentrations below the
expected human therapeutic average serum concentrations. In rabbits, bevacizumab was shown to
inhibit wound healing at doses below the proposed clinical dose. Effects on wound healing were
shown to be fully reversible.
Studies to evaluate the mutagenic and carcinogenic potential of bevacizumab have not been performed.
No specific studies in animals have been conducted to evaluate the effect on fertility. An adverse
effect on female fertility can however be expected as repeat dose toxicity studies in animals have
shown inhibition of the maturation of ovarian follicles and a decrease/absence of corpora lutea and
associated decrease in ovarian and uterus weight as well as a decrease in the number of menstrual
cycles.
51
Bevacizumab has been shown to be embryotoxic and teratogenic when administered to rabbits.
Observed effects included decreases in maternal and foetal body weights, an increased number of
foetal resorptions and an increased incidence of specific gross and skeletal foetal malformations.
Adverse foetal outcomes were observed at all tested doses, of which the lowest dose resulted in
average serum concentrations approximately 3 times larger than in humans receiving 5 mg/kg every
2 weeks. Information on foetal malformations observed in the post marketing setting are provided in
section 4.6 Fertility, Pregnancy and Lactation and 4.8 Undesirable Effects.
6. PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Trehalose dihydrate
Sodium phosphate
Polysorbate 20
Water for injections
6.2 Incompatibilities
This medicinal product must not be mixed with other medicinal products except those mentioned in
section 6.6.
A concentration dependent degradation profile of bevacizumab was observed when diluted with
glucose solutions (5%).
6.3 Shelf life
Vial (unopened)
2 years.
Diluted medicinal product
Chemical and physical in-use stability has been demonstrated for 30 days at 2°C to 8°C plus an
additional 48 hours at 2°C to 30°C in sodium chloride 9 mg/ml (0.9%) solution for injection. From a
microbiological point of view, the product should be used immediately. If not used immediately, in-
use storage times and conditions are the responsibility of the user and would normally not be longer
than 24 hours at 2°C to 8°C, unless dilution has taken place in controlled and validated aseptic
conditions.
6.4 Special precautions for storage
Store in a refrigerator (2°C-8°C).

Do not freeze.
Keep the vial in the outer carton in order to protect from light.
For storage conditions after dilution of the medicinal product, see section 6.3.
6.5 Nature and contents of container
4 ml solution in a vial (Type I glass) with a stopper (butyl rubber) containing 100 mg of bevacizumab.
16 ml solution in a vial (Type I glass) with a stopper (butyl rubber) containing 400 mg of bevacizumab.
Pack of 1 vial.
52
6.6 Special precautions for disposal and other handling
Avastin should be prepared by a healthcare professional using aseptic technique to ensure the sterility
of the prepared solution.
The necessary amount of bevacizumab should be withdrawn and diluted to the required administration
volume with sodium chloride 9 mg/ml (0.9%) solution for injection. The concentration of the final
bevacizumab solution should be kept within the range of 1.4 mg/ml to 16.5 mg/ml. In the majority of
the occasions the necessary amount of Avastin can be diluted with 0.9 % sodium chloride solution for
injection to a total volume of 100 mL.
Parenteral medicinal products should be inspected visually for particulate matter and discolouration
prior to administration.
No incompatibilities between Avastin and polyvinyl chloride or polyolefine bags or infusion sets have
been observed.
Avastin is for single-use only, as the product contains no preservatives. Any unused medicinal product
or waste material should be disposed in accordance with local requirements.
7. MARKETING AUTHORISATION HOLDER
Roche Registration GmbH

Emil-Barell-Strasse 1
79639 Grenzach-Wyhlen
Germany
8. MARKETING AUTHORISATION NUMBER(S)
EU/1/04/300/001 – 100 mg/4 ml vial

EU/1/04/300/002 – 400 mg/16 ml vial
9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: 12 January 2005

Date of latest renewal: 14 January 2015
10. DATE OF REVISION OF THE TEXT
Detailed information on this medicinal product is available on the website of the European Medicines
Agency (EMA): http://www.ema.europa.eu
53
ANNEX II
A. MANUFACTURERS OF THE BIOLOGICAL ACTIVE

SUBSTANCE AND MANUFACTURER RESPONSIBLE FOR
BATCH RELEASE
B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY

AND USE
C. OTHER CONDITIONS AND REQUIREMENTS OF THE

MARKETING AUTHORISATION
D. CONDITIONS OR RESTRICTIONS WITH REGARD TO

THE SAFE AND EFFECTIVE USE OF THE MEDICINAL
PRODUCT
54
A. MANUFACTURERS OF THE BIOLOGICAL ACTIVE SUBSTANCE AND
MANUFACTURER RESPONSIBLE FOR BATCH RELEASE
Name and address of the manufacturers of the biological active substance
Genentech, Inc.
1 DNA Way
South San Francisco, CA 94080-4990
USA
Genentech, Inc.
1 Antibody Way
Oceanside, CA 92056
USA
F. Hoffmann-La Roche Ltd

Grenzacherstrasse 124
CH-4070 Basel
Switzerland
Roche Singapore Technical Operations, Pte. Ltd.

10 Tuas Bay Link
Singapore 637394
Singapore
Name and address of the manufacturer responsible for batch release
Roche Pharma AG
Emil-Barrell-Str. 1,
D-79639 Grenzach-Wyhlen
Germany
B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE
Medicinal product subject to restricted medical prescription (see Annex I: Summary of Product
Characteristics, section 4.2).
C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING

AUTHORISATION
● Periodic safety update reports (PSURs)
The requirements for submission of PSURs for this medicinal product are set out in the list of Union
reference dates (EURD list) provided for under Article 107c(7) of Directive 2001/83/EC and any
subsequent updates published on the European medicines web-portal.
D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND

EFFECTIVE USE OF THE MEDICINAL PRODUCT
● Risk management plan (RMP)

The marketing authorisation holder (MAH) shall perform the required pharmacovigilance activities
and interventions detailed in the agreed RMP presented in Module 1.8.2 of the marketing authorisation
and any agreed subsequent updates of the RMP.
55
An updated RMP should be submitted:
● At the request of the European Medicines Agency;
● Whenever the risk management system is modified, especially as the result of new information
being received that may lead to a significant change to the benefit/risk profile or as the result of
an important (pharmacovigilance or risk minimisation) milestone being reached.
56
ANNEX III
LABELLING AND PACKAGE LEAFLET
57
A. LABELLING
58
PARTICULARS TO APPEAR ON THE OUTER PACKAGING
CARTON
Avastin 25 mg/ml concentrate for solution for infusion

bevacizumab
2. STATEMENT OF ACTIVE SUBSTANCE(S)
Each vial contains 100 mg bevacizumab.
3. LIST OF EXCIPIENTS
Trehalose dihydrate, sodium phosphate, polysorbate 20, water for injections.
4. PHARMACEUTICAL FORM AND CONTENTS
Concentrate for solution for infusion

1 vial of 4 ml
100 mg/4 ml
5. METHOD AND ROUTE(S) OF ADMINISTRATION
For intravenous use after dilution

Read the package leaflet before use
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT

OF THE SIGHT AND REACH OF CHILDREN
Keep out of the sight and reach of children
7. OTHER SPECIAL WARNING(S), IF NECESSARY
This medicinal product does not contain any preservative
8. EXPIRY DATE
EXP
Read the leaflet for the shelf life of the diluted medicine
9. SPECIAL STORAGE CONDITIONS
Store in a refrigerator (2°C – 8°C).

Do not freeze.
Keep the vial in the outer carton
59
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF
APPROPRIATE
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Germany
EU/1/04/300/001
13. BATCH NUMBER
Batch
14. GENERAL CLASSIFICATION FOR SUPPLY
Medicinal product subject to medical prescription
15. INSTRUCTIONS ON USE
16. INFORMATION IN BRAILLE
Justification for not including Braille accepted
17. UNIQUE IDENTIFIER – 2D BARCODE
<2D barcode carrying the unique identifier included.>
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA
PC:
SN:
NN:
60
MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS
VIAL
1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

bevacizumab
IV
2. METHOD OF ADMINISTRATION
3. EXPIRY DATE
EXP
4. BATCH NUMBER
Lot
5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT
100 mg/4 ml
6. OTHER
61
PARTICULARS TO APPEAR ON THE OUTER PACKAGING
CARTON

bevacizumab
2. STATEMENT OF ACTIVE SUBSTANCE(S)
Each vial contains 400 mg bevacizumab.
3. LIST OF EXCIPIENTS
Trehalose dihydrate, sodium phosphate, polysorbate 20, water for injections.
4. PHARMACEUTICAL FORM AND CONTENTS
Concentrate for solution for infusion

1 vial of 16 ml
400 mg/16 ml
5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use
6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT

OF THE SIGHT AND REACH OF CHILDREN
Keep out of the sight and reach of children
7. OTHER SPECIAL WARNING(S), IF NECESSARY
This medicinal product does not contain any preservative
8. EXPIRY DATE
EXP
Read the leaflet for the shelf life of the diluted medicine
9. SPECIAL STORAGE CONDITIONS
Store in a refrigerator (2°C – 8°C).

Do not freeze.
Keep the vial in the outer carton
62
10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF
APPROPRIATE
11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Germany
EU/1/04/300/002
13. BATCH NUMBER
Batch
14. GENERAL CLASSIFICATION FOR SUPPLY
Medicinal product subject to medical prescription
15. INSTRUCTIONS ON USE
16. INFORMATION IN BRAILLE
Justification for not including Braille accepted
17. UNIQUE IDENTIFIER – 2D BARCODE
<2D barcode carrying the unique identifier included.>
18. UNIQUE IDENTIFIER - HUMAN READABLE DATA
PC:
SN:
NN:
63
MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS
VIAL
1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

bevacizumab
IV
2. METHOD OF ADMINISTRATION
3. EXPIRY DATE
EXP
4. BATCH NUMBER
Lot
5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT
400 mg/16 ml
6. OTHER
64
B. PACKAGE LEAFLET
65
Package leaflet: Information for the user

bevacizumab
Read all of this leaflet carefully before you start using this medicine because it contains
important information for you.
● Keep this leaflet. You may need to read it again.
● If you have any further questions, ask your doctor, pharmacist or nurse.
● If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible
side effects not listed in this leaflet. See Section 4.
What is in this leaflet:
1. What Avastin is and what it is used for

2. What you need to know before you use Avastin
3. How to use Avastin
4. Possible side effects
5. How to store Avastin
6. Contents of the pack and other information
1. What Avastin is and what it is used for
Avastin contains the active substance bevacizumab, which is a humanised monoclonal antibody (a
type of protein that is normally made by the immune system to help defend the body from infection
and cancer). Bevacizumab binds selectively to a protein called human vascular endothelial growth
factor (VEGF), which is found on the lining of blood and lymph vessels in the body. The VEGF
protein causes blood vessels to grow within tumours, these blood vessels provide the tumour with
nutrients and oxygen. Once bevacizumab is bound to VEGF, tumour growth is prevented by blocking
the growth of the blood vessels which provide the nutrients and oxygen to the tumour.
Avastin is a medicine used for the treatment of adult patients with advanced cancer in the large bowel,
i.e., in the colon or rectum. Avastin will be administered in combination with chemotherapy treatment
containing a fluoropyrimidine medicine.
Avastin is also used for the treatment of adult patients with metastatic breast cancer. When used for
patients with breast cancer, it will be administered with a chemotherapy medicinal product called
paclitaxel or capecitabine.
Avastin is also used for the treatment of adult patients with advanced non-small cell lung cancer.
Avastin will be administered together with a chemotherapy regimen containing platinum.
Avastin is also used for the treatment of adult patients with advanced non-small cell lung cancer when
cancer cells have specific mutations of a protein called epidermal growth factor receptor (EGFR).
Avastin will be administered in combination with erlotinib.
Avastin is also used for treatment of adult patients with advanced kidney cancer. When used for
patients with kidney cancer, it will be administered with another type of medicine called interferon.
Avastin is also used for the treatment of adult patients with advanced epithelial ovarian, fallopian tube,
or primary peritoneal cancer. When used for patients with epithelial ovarian, fallopian tube, or primary
peritoneal cancer, it will be administered in combination with carboplatin and paclitaxel.
When used for those adult patients with advanced epithelial ovarian, fallopian tube, or primary
peritoneal cancer whose disease has come back at least 6 months after the last time they were treated
66
with a chemotherapy regimen containing a platinum agent, Avastin will be administered in
combination with carboplatin and gemcitabine or with carboplatin and paclitaxel.
When used for those adult patients with advanced epithelial ovarian, fallopian tube, or primary
peritoneal cancer whose disease has come back before 6 months after the last time they were treated
with a chemotherapy regimen containing a platinum agent, Avastin will be administered in
combination with paclitaxel, or topotecan, or pegylated liposomal doxorubicin.
Avastin is also used for the treatment of adult patients with persistent, recurrent or metastatic cervical
cancer. Avastin will be administered in combination with paclitaxel and cisplatin or, alternatively,
paclitaxel and topotecan in patients who cannot receive platinum therapy.
2. What you need to know before you use Avastin
Do not use Avastin if

● you are allergic (hypersensitive) to bevacizumab or to any of the other ingredients of this
medicine (listed in section 6).
● you are allergic (hypersensitive) to Chinese hamster ovary (CHO) cell products or to other
recombinant human or humanised antibodies.
● you are pregnant.
Warnings and precautions

Talk to your doctor, pharmacist or nurse before using Avastin
● It is possible that Avastin may increase the risk of developing holes in the gut wall. If you have
conditions causing inflammation inside the abdomen (e.g. diverticulitis, stomach ulcers, colitis
associated with chemotherapy), please discuss this with your doctor.
● Avastin may increase the risk of developing an abnormal connection or passageway between
two organs or vessels. The risk of developing connections between the vagina and any parts of
the gut can increase if you have persistent, recurrent or metastatic cervical cancer.
● This medicine can increase the risk of bleeding or increase the risk of problems with wound
healing after surgery. If you are going to have an operation, if you have had major surgery
within the last 28 days or if you still have an unhealed wound following surgery, you should not
receive this medicine.
● Avastin may increase the risk of developing serious infections of the skin or deeper layers under
the skin, especially if you had holes in the gut wall or problems with wound healing.
● Avastin can increase the incidence of high blood pressure. If you have high blood pressure
which is not well controlled with blood pressure medicines, please consult your doctor as it is
important to make sure that your blood pressure is under control before starting Avastin
treatment.
● If you have or have had an aneurysm (enlargement and weakening of a blood vessel wall) or a
tear in a blood vessel wall.
● This medicine increases the risk of having protein in your urine especially if you already have
high blood pressure.
● The risk of developing blood clots in your arteries (a type of blood vessel) can increase if you
are over 65 years old, if you have diabetes, or if you have had previous blood clots in your
arteries. Please talk to your doctor since blood clots can lead to heart attack and stroke.
67
● Avastin can also increase the risk of developing blood clots in your veins (a type of blood
vessel).
● This medicine may cause bleeding, especially tumour-related bleeding. Please consult your
doctor if you or your family tend to suffer from bleeding problems or you are taking medicines
to thin the blood for any reason.
● It is possible that Avastin may cause bleeding in and around your brain. Please discuss this with
your doctor if you have metastatic cancer affecting your brain.
● It is possible that Avastin can increase the risk of bleeding in your lungs, including coughing or
spitting blood. Please discuss with your doctor if you noticed this previously.
● Avastin can increase the risk of developing a weak heart. It is important that your doctor knows
if you have ever received anthracyclines (for example doxorubicin, a specific type of
chemotherapy used to treat some cancers) or had radiotherapy to your chest, or if you have heart
disease.
● This medicine may cause infections and a decreased number of your neutrophils (a type of
blood cell important for your protection against bacteria).
● It is possible that Avastin can cause hypersensitivity and/or infusion reactions (reactions related
to your injection of the medicine). Please let your doctor, pharmacist or nurse know if you have
previously experienced problems after injections, such as dizziness/feeling of fainting,
breathlessness, swelling or skin rash.
● A rare neurological side effect named posterior reversible encephalopathy syndrome (PRES)
has been associated with Avastin treatment. If you have headache, vision changes, confusion or
seizure with or without high blood pressure, please contact your doctor.
Please consult your doctor, even if these above statements were only applicable to you in the past.
Before you are given Avastin or while you are being treated with Avastin:
● if you have or have had pain in the mouth, teeth and/or jaw, swelling or sores inside the mouth,
numbness or a feeling of heaviness in the jaw, or loosening of a tooth tell your doctor and
dentist immediately.
● if you need to undergo an invasive dental treatment or dental surgery, tell your dentist that you
are being treated with Avastin, in particular when you are also receiving or have received an
injection of bisphosphonate into your blood.
You may be advised to have a dental check-up before you start treatment with Avastin.
Children and adolescents

Avastin use is not recommended in children and adolescents under the age of 18 years because the
safety and benefit have not been established in these patient populations.
Death of bone tissue (osteonecrosis) in bones other than the jaw have been reported in patients under
18 years old when treated with Avastin.
Other medicines and Avastin

Tell your doctor, pharmacist or nurse if you are taking, have recently taken or might take any other
medicines.
Combinations of Avastin with another medicine called sunitinib malate (prescribed for renal and
gastrointestinal cancer) may cause severe side effects. Discuss with your doctor to make sure that you
do not combine these medicine.
68
Tell your doctor if you are using platinum- or taxane-based therapies for lung or metastatic breast
cancer. These therapies in combination with Avastin may increase the risk of severe side effects.
Please tell your doctor if you have recently received, or are receiving, radiotherapy.
Pregnancy, breast feeding and fertility

You must not use this medicine if you are pregnant. Avastin may cause damage to your unborn baby
as it may stop the formation of new blood vessels. Your doctor should advise you about using
contraception during treatment with Avastin and for at least 6 months after the last dose of Avastin.
Tell your doctor straightaway if you are pregnant, become pregnant during treatment with this
medicine, or plan to become pregnant in the near future.
You must not breast-feed your baby during treatment with Avastin and for at least 6 months after the
last dose of Avastin, as this medicine may interfere with the growth and development of your baby.
Avastin may impair female fertility. Please consult your doctor for more information.
Ask your doctor, pharmacist or nurse for advice before taking any medicine.
Driving and using machines

Avastin has not been shown to reduce your ability to drive or to use any tools or machines. However,
sleepiness and fainting have been reported with Avastin use. If you experience symptoms that affect
your vision or concentration, or your ability to react, do not drive and use machines until symptoms
disappear.
Important information about some of the ingredients of Avastin

This medicine contains less than 1 mmol sodium (23 mg) per vial, that is to say essentially ‘sodium-
free’.
3. How to use Avastin
Dosage and frequency of administration

The dose of Avastin needed depends on your body weight and the kind of cancer to be treated. The
recommended dose is 5 mg, 7.5 mg, 10 mg or 15 mg per kilogram of your body weight. Your doctor
will prescribe a dose of Avastin that is right for you. You will be treated with Avastin once every 2 or
3 weeks. The number of infusions that you receive will depend on how you are responding to
treatment; you should continue to receive this medicine until Avastin fails to stop your tumour
growing. Your doctor will discuss this with you.
Method and route of administration

Avastin is a concentrate for solution for infusion. Depending on the dose prescribed for you, some or
all of the contents of the Avastin vial will be diluted with sodium chloride solution before use. A
doctor or nurse will give you this diluted Avastin solution by intravenous infusion (a drip into your
vein). The first infusion will be given to you over 90 minutes. If this is well-tolerated the second
infusion may be given over 60 minutes. Later infusions may be given to you over 30 minutes.
The administration of Avastin should be temporarily discontinued

● if you develop severe high blood pressure requiring treatment with blood pressure medicines,
● if you have problems with wound healing following surgery,
● if you undergo surgery.
The administration of Avastin should be permanently discontinued if you develop

● severe high blood pressure which cannot be controlled by blood pressure medicines; or a sudden
severe rise in blood pressure,
● presence of protein in your urine accompanied by swelling of your body,
69
● a hole in your gut wall,
● an abnormal tube-like connection or passage between the windpipe and the gullet, between
internal organs and skin, between the vagina and any parts of the gut or between other tissues
that are not normally connected (fistula), and are judged by your doctor to be severe,
● serious infections of the skin or deeper layers under the skin,
● a blood clot in your arteries,
● a blood clot in the blood vessels of your lungs,
● any severe bleeding.
If too much Avastin is given

● you may develop a severe migraine. If this happens you should talk to your doctor, pharmacist
or nurse immediately.
If a dose of Avastin is missed

● your doctor will decide when you should be given your next dose of Avastin. You should
discuss this with your doctor.
If you stop treatment with Avastin

Stopping your treatment with Avastin may stop the effect on tumour growth. Do not stop treatment
with Avastin unless you have discussed this with your doctor.
If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.
4. Possible side effects
Like all medicines, this medicine can cause side effects, although not everybody gets them.
If you get any side effects talk to your doctor, pharmacist or nurse. This includes any possible side
effects not listed in this leaflet.
The side effects listed below were seen when Avastin was given together with chemotherapy. This
does not necessarily mean that these side effects were strictly caused by Avastin.
Allergic reactions
If you have an allergic reaction, tell your doctor or a member of the medical staff straight away. The
signs may include: difficulty in breathing or chest pain. You could also experience redness or flushing
of the skin or a rash, chills and shivering, feeling sick (nausea) or being sick (vomiting).
You should seek help immediately if you suffer from any of the below mentioned side effects.
Severe side effects, which may be very common (affects more than 1 user in 10), include:
• high blood pressure,
• feeling of numbness or tingling in hands or feet,
• decreased number of cells in the blood, including white cells that help to fight against infections
(this may be accompanied by fever), and cells that help the blood to clot,
• feeling weak and having no energy,
• tiredness,
• diarrhoea, nausea, vomiting and abdominal pain.
Severe side effects, which may be common (affects 1 to 10 users in 100), include:
• perforation of the gut,
• bleeding, including bleeding in the lungs in patients with non-small cell lung cancer,
• blocking of the arteries by a blood clot,
• blocking of the veins by a blood clot,
• blocking of the blood vessels of the lungs by a blood clot,
• blocking of the veins of the legs by a blood clot,
70
• heart failure,
• problems with wound healing after surgery,
• redness, peeling, tenderness, pain, or blistering on the fingers or feet,
• decreased number of red cells in the blood,
• lack of energy,
• stomach and intestinal disorder,
• muscle and joint pain, muscular weakness,
• dry mouth in combination with thirst and/or reduced or darkened urine,
• inflammation of the moist lining of mouth and gut, lungs and air passages, reproductive, and
urinary tracts,
• sores in the mouth and the tube from the mouth to the stomach, which may be painful and cause
difficulty swallowing,
• pain, including headache, back pain and pain in the pelvis and anal regions,
• localised pus collection,
• infection, and in particular infection in the blood or bladder,
• reduced blood supply to the brain or stroke,
• sleepiness,
• nose bleed,
• increase in heart rate (pulse),
• blockage in the gut or bowel,
• abnormal urine test (protein in the urine),
• shortness of breath or low levels of oxygen in the blood,
• infections of the skin or deeper layers under the skin,
• fistula: abnormal tube-like connection between internal organs and skin or other tissues that are
not normally connected, including connections between vagina and the gut in patients with
cervical cancer.
Severe side effects of unknown frequency (frequency cannot be estimated from the available data),
include:
• serious infections of the skin or deeper layers under the skin, especially if you had holes in the gut
wall or problems with wound healing,
• allergic reactions (the signs may include difficulty breathing, facial redness, rash, low blood
pressure or high blood pressure, low oxygen in your blood, chest pain, or nausea/vomiting),
• a negative effect on a woman’s ability to have children (see the paragraphs below the list of side
effects for further recommendations),
• a brain condition with symptoms including seizures (fits), headache, confusion, and changes in
vision (Posterior Reversible Encephalopathy Syndrome or PRES),
• symptoms that suggest changes in normal brain function (headaches, vision changes, confusion,
or seizures), and high blood pressure,
• an enlargement and weakening of a blood vessel wall or a tear in a blood vessel wall (aneurysms
and artery dissections),
• clogging of a very small blood vessel(s) in the kidney,
• abnormally high blood pressure in the blood vessels of the lungs which makes the right side of the
heart work harder than normal,
• a hole in the cartilage wall separating the nostrils of the nose,
• a hole in the stomach or intestines,
• an open sore or hole in the lining of the stomach or small intestine (the signs may include
abdominal pain, feeling bloated, black tarry stools or blood in your stools (faeces) or blood in
your vomit),
• bleeding from the lower part of the large bowel,
• lesions in the gums with an exposed jaw bone that does not heal and may be associated with pain
and inflammation of the surrounding tissue (see the paragraphs below the list of side effects for
further recommendations),
• hole in the gall bladder (symptoms and signs may include abdominal pain, fever, and
nausea/vomiting).
71
You should seek help as soon as possible if you suffer from any of the below mentioned side
effects.
Very common (affects more than 1 user in 10) side effects, which were not severe, include:
• constipation,
• loss of appetite,
• fever,
• problems with the eyes (including increased production of tears),
• changes in speech,
• change in the sense of taste,
• runny nose,
• dry skin, flaking and inflammation of the skin, change in skin colour,
• loss of body weight,
• nose bleeds.
Common (affects 1 to 10 users in 100) side effects, which were not severe, include:
• voice changes and hoarseness.
Patients older than 65 years have an increased risk of experiencing the following side effects :
• blood clot in the arteries which can lead to a stroke or a heart attack,
• reduction in the number of white cells in the blood, and cells that help the blood clot,
• diarrhoea,
• sickness,
• headache,
• fatigue,
• high blood pressure.
Avastin may also cause changes in laboratory tests carried out by your doctor. These include a
decreased number of white cells in the blood, in particular neutrophils (one type of white blood cell
which helps protect against infections) in the blood; presence of protein in the urine; decreased blood
potassium, sodium or phosphorous (a mineral); increased blood sugar; increased blood alkaline
phosphatase (an enzyme); increased serum creatinine (a protein measured by a blood test to see how
well your kidneys are working); decreased haemoglobin (found in red blood cells, which carry oxygen),
which may be severe.
Pain in the mouth, teeth and/or jaw, swelling or sores inside the mouth, numbness or a feeling of
heaviness in the jaw, or loosening of a tooth. These could be signs and symptoms of bone damage in
the jaw (osteonecrosis). Tell your doctor and dentist immediately if you experience any of them.
Pre-menopausal women (women who have a menstrual cycle) may notice that their periods become
irregular or are missed and may experience impaired fertility. If you are considering having children
you should discuss this with your doctor before your treatment starts.
Avastin has been developed and made to treat cancer by injecting it into the bloodstream. It has not
been developed or made for injection into the eye. It is therefore not authorised to be used in this way.
When Avastin is injected directly into the eye (unapproved use), the following side effects may occur:
• Infection or inflammation of the eye globe,

• Redness of the eye, small particles or spots in your vision (floaters), eye pain,
• Seeing flashes of light with floaters, progressing to a loss of some of your vision,
• Increased eye pressure,
• Bleeding in the eye.
Reporting of side effects

If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side
effects not listed in this leaflet. You can also report side effects directly via the national reporting
72
system listed in Appendix V. By reporting side effects you can help provide more information on the
safety of this medicine.
5. How to store Avastin
Keep this medicine out of the sight and reach of children.
Do not use this medicine after the expiry date which is stated on the outer carton and on the vial label
after the abbreviation EXP. The expiry date refers to the last day of that month.
Store in a refrigerator (2°C–8°C).

Do not freeze.
Keep the vial in the outer carton in order to protect from light.
Infusion solutions should be used immediately after dilution. If not used immediately, in-use storage
times and conditions are the responsibility of the user and would normally not be longer than 24 hours
at 2°C to 8°C, unless the infusion solutions have been prepared in a sterile environment. When dilution
has taken place in a sterile environment, Avastin is stable for 30 days at 2°C to 8°C plus an additional
48 hours at 2°C to 30°C.
Do not use Avastin if you notice any particulate matter or discolouration prior to administration.
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to
throw away medicines you no longer use. These measures will help to protect the environment.
6. Contents of the pack and other information
What Avastin contains
• The active substance is bevacizumab. Each ml of concentrate contains 25 mg of bevacizumab,

corresponding to 1.4 to 16.5 mg/ml when diluted as recommended.
Each 4 ml vial contains 100 mg of bevacizumab, corresponding to 1.4 mg/ml when diluted as
recommended.
Each 16 ml vial contains 400 mg of bevacizumab, corresponding to 16.5 mg/ml when diluted as
recommended
• The other ingredients are trehalose dihydrate, sodium phosphate, polysorbate 20 and water for
injections.
What Avastin looks like and contents of the pack

Avastin is a concentrate for solution for infusion. The concentrate is a clear, colourless to pale brown
liquid in a glass vial with a rubber stopper. Each vial contains 100 mg bevacizumab in 4 ml of solution
or 400 mg bevacizumab in 16 ml of solution. Each pack of Avastin contains one vial.
Marketing Authorisation Holder

Germany
Manufacturer
Roche Pharma AG
Emil-Barell-Str. 1
Germany
73
For any information about this medicine, please contact the local representative of the Marketing
Authorisation Holder.
België/Belgique/Belgien Lietuva
N.V. Roche S.A. UAB “Roche Lietuva”
Tél/Tel: +32 (0) 2 525 82 11 Tel: +370 5 2546799
България Luxembourg/Luxemburg
Рош България ЕООД (Voir/siehe Belgique/Belgien)
Тел: +359 2 818 44 44
Česká republika Magyarország

Roche s. r. o. Roche (Magyarország) Kft.
Tel: +420 - 2 20382111 Tel: +36 - 23 446 800
Danmark Malta
Roche a/s (See Ireland)
Tlf: +45 - 36 39 99 99
Deutschland Nederland
Roche Pharma AG Roche Nederland B.V.
Tel: +49 (0) 7624 140 Tel: +31 (0) 348 438050
Eesti Norge
Roche Eesti OÜ Roche Norge AS
Tel: + 372 - 6 177 380 Tlf: +47 - 22 78 90 00
Ελλάδα Österreich
Roche (Hellas) A.E. Roche Austria GmbH
Τηλ: +30 210 61 66 100 Tel: +43 (0) 1 27739
España Polska
Roche Farma S.A. Roche Polska Sp.z o.o.
Tel: +34 - 91 324 81 00 Tel: +48 - 22 345 18 88
France Portugal
Roche Roche Farmacêutica Química, Lda
Tél: +33 (0) 1 47 61 40 00 Tel: +351 - 21 425 70 00
Hrvatska România
Roche d.o.o. Roche România S.R.L.
Tel: + 385 1 47 22 333 Tel: +40 21 206 47 01
Ireland Slovenija
Roche Products (Ireland) Ltd. Roche farmacevtska družba d.o.o.
Tel: +353 (0) 1 469 0700 Tel: +386 - 1 360 26 00
Ísland Slovenská republika

Roche a/s Roche Slovensko, s.r.o.
c/o Icepharma hf Tel: +421 - 2 52638201
Sími:+354 540 8000
Italia Suomi/Finland
Roche S.p.A. Roche Oy
Tel: +39 - 039 2471 Puh/Tel: +358 (0) 10 554 500
74
Kύπρος Sverige
Γ.Α.Σταμάτης & Σια Λτδ. Roche AB
Τηλ: +357 - 22 76 62 76 Tel: +46 (0) 8 726 1200
Latvija United Kingdom

Roche Latvija SIA Roche Products Ltd.
Tel: +371 - 6 7039831 Tel: +44 (0) 1707 366000
This leaflet was last revised in
Other sources of information
Detailed information on this medicine is available on the European Medicines Agency web site:
http://www.ema.europa.eu.
75

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ANNEX I

SUMMARY OF PRODUCT CHARACTERISTICS

Avastin 25 mg/ml concentrate for solution for infusion.

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each ml of concentrate contains 25 mg of bevacizumab*.

*Bevacizumab is a recombinant humanised monoclonal antibody produced by DNA technology in

For the full list of excipients, see section 6.1.

Concentrate for solution for infusion.

Clear to slightly opalescent, colourless to pale brown liquid.

4.1 Therapeutic indications

Bevacizumab in combination with fluoropyrimidine-based chemotherapy is indicated for treatment of

Bevacizumab, in addition to platinum-based chemotherapy, is indicated for first-line treatment of adult

Bevacizumab in combination with paclitaxel, topotecan, or pegylated liposomal doxorubicin is

4.2 Posology and method of administration

Metastatic carcinoma of the colon or rectum (mCRC)

The recommended dose of Avastin, administered as an intravenous infusion, is either 5 mg/kg or

Metastatic breast cancer (mBC)

Non-small cell lung cancer (NSCLC)

First-line treatment of non-squamous NSCLC in combination with platinum-based chemotherapy

Avastin is administered in addition to platinum-based chemotherapy for up to 6 cycles of treatment

Advanced and/or metastatic renal cell cancer (mRCC)

Epithelial ovarian, fallopian tube and primary peritoneal cancer

Front-line treatment: Avastin is administered in addition to carboplatin and paclitaxel for up to 6

Treatment of platinum-sensitive recurrent disease: Avastin is administered in combination with either

Treatment of platinum-resistant recurrent disease: Avastin is administered in combination with one of

Elderly patients: No dose adjustment is required in the patients ≥ 65 years of age.

It should not be administered as an intravenous push or bolus.

Precautions to be taken before handling or administering the medicinal product

4.4 Special warnings and precautions for use

Gastrointestinal (GI) perforations and Fistulae (see section 4.8)

GI-vaginal Fistulae in study GOG-0240

Wound healing complications (see section 4.8)

Hypertension (see section 4.8)

Posterior Reversible Encephalopathy Syndrome (PRES) (see section 4.8)

Proteinuria (see section 4.8)

Arterial thromboembolism (see section 4.8)

Therapy should be permanently discontinued in patients who develop arterial thromboembolic

Venous thromboembolism (see section 4.8)

Aneurysms and artery dissections

Congestive heart failure (CHF) (see section 4.8)

Neutropenia and infections (see section 4.8)

Hypersensitivity reactions/infusion reactions (see section 4.8)

Osteonecrosis of the jaw (ONJ) (see section 4.8)

Systemic effects following intravitreal use

Effect of antineoplastic agents on bevacizumab pharmacokinetics

Effect of bevacizumab on the pharmacokinetics of other antineoplastic agents

Combination of bevacizumab and sunitinib malate

EGFR monoclonal antibodies in combination with bevacizumab chemotherapy regimens

4.6 Fertility, pregnancy and lactation

Women of childbearing potential

4.7 Effects on ability to drive and use machines

4.8 Undesirable effects

Summary of the safety profile

The most serious adverse reactions were:

• Gastrointestinal perforations (see section 4.4).

Tabulated list of adverse reactions

Infections and Sepsis, Necrotising

Nervous system Peripheral sensory Cerebrovascular Posterior Hypertensive

Eye disorders Eye disorder,