A Phase II Trial Assessing Nivolumab in Class II Expressing Microsatellite Stable Colorectal Cancer
Phase: PHASE2
Conditions: Colorectal Cancer
Sponsor: University of Birmingham

 
 
 
 
 
 
 
 
 
 
 
 
A phase II trial assessing nivolumab in class II expressing 
microsatellite stable colorectal cancer  
 
 
Protocol 
Version 7.0, 01-Nov-2021 
 
 
 
 
 
 
 
 
 
 
 
 
Sponsor 
University of Birmingham 
Sponsor Protocol Number  
RG_17-215 
CRCTU Number 
CR2008 
ISRCTN  
40245896 
IRAS ID 
237804 
EudraCT Number: 
2018-000318-39 

 
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ANICCA Protocol v7.0 01-Nov-2021 
 
 
 
 
 
 
 
 
 
 
ANICCA-Class II Trial Office 
Cancer Research UK Clinical Trials Unit (CRCTU) 
Institute of Cancer and Genomic Sciences 
University of Birmingham 
B15 2TT 
 
Tel: 0121 414 6754 
Email: ANICCA-ClassII@trials.bham.ac.uk 
Patient Registration 
 
https://www.cancertrials.bham.ac.uk/ANICCAClassIILive 
Serious Adverse Event Reporting 
 
Email: reg@trials.bham.ac.uk 

 
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ANICCA Protocol v7.0 01-Nov-2021 
 
TRIAL MANAGEMENT GROUP 
Chief Investigator 
Professor Gary Middleton 
Institute of Cancer & Genomic Sciences, 
University of Birmingham 
Clinical Coordinators 
Professor John Bridgewater 
University College London  
Dr Paul Ross 
Guy’s Hospital 
Lead Statistician 
Professor Lucinda Billingham 
Biostatistics Team, CRCTU, University of 
Birmingham 
Trial Histopathologist 
Dr Phillipe Taniere 
The Queen Elizabeth Hospital, Birmingham 
Trial Management Team Leader 
Dr Joshua Savage 
Early Drug Development Team, CRCTU, 
University of Birmingham  
Trial Coordinator 
Ms Jessica Crook 
Early Drug Development Team, CRCTU, 
University of Birmingham 
Trial Statistician 
Ms Wenyu Liu 
Biostatistics Team, CRCTU, University of 
Birmingham 
Patient Representatives 
Mr Len Evans 
Mrs Susan Ann Smith 
 
 
 

 
Page v 
 
ANICCA Protocol v7.0 01-Nov-2021 
 
AMENDMENTS 
 
The following amendments and/or administrative changes have been made to this protocol 
since the implementation of the first approved version: 
Amendment 
number 
Date of 
amendment 
Protocol 
version 
number 
Type of 
amendment 
Summary of amendment 
1 
02-Apr-2019 
3.0 
Substantial 
• 
Change to collect only month and year 
for date of birth. 
• 
Clarification of follow-up period for 
pregnancies. 
2 
14-Nov-2019 
4.0 
Substantial 
• 
Addition of ISRCTN 
• 
Section 5.2: eRDC webpage amended 
• 
Addition of wording for new biopsy if 
archival biopsy is not sufficient or 
available 
• 
Change of PI at Beatson Cancer Centre 
3 
20 May 2020 
5.0 
Substantial 
• 
Change in Class II expression 
requirements for eligibility 
• 
Addition of wording to allow treatment 
beyond progression if there is clinical 
benefit 
• 
Removal of fax number throughout 
• 
Clarification of pregnancy test 
requirements 
• 
Changes to assessment time points 
within the schedule of events to 
accommodate treatment dose changes. 
• 
Change to treatment dose and schedule 
from 2 to 4 weekly.  
• 
Addition of exploratory objective. 
6 
24-Aug-2021 
6.0 
Substantial 
• 
Changes to Table 3: Dose modification 
and toxicity management guidelines for 
immune-related AEs associated with 
nivolumab to include guidance from 
SPC (24-Aug-2020) 
• 
Text added to schedule of assesments 
to clarify when an isotopic EGFR is 
needed 
• 
Text added to schedule of assesments 
to clarify the date that CT scans should 
be scheduled from. 
• 
Schedule of Assessment tables 
updated to reflect that where applicable 
and acceptable in accordance to local 
practices, visits/assesments may be 
performed by telephone or video call. 
• 
Process for remote consent added. 
• 
Information relating to COVID-19 added 
  
8 
01-Nov-2021 
7.0 
 
• 
Changes to Table 3 : Dose modification 
and toxicity management guidelines for 
immune-related AEs associated with 
nivolumab to include guidance from 
SPC  

 
Page vi 
 
ANICCA Protocol v7.0 01-Nov-2021 
 
 
 

 
Page vii 
 
ANICCA Protocol v7.0 01-Nov-2021 
 
TRIAL SYNOPSIS 
Title 
ANICCA-Class II: A phase II trial assessing nivolumab in class II 
expressing microsatellite stable colorectal cancer (MSS CRC) 
Trial Design 
An open-label, single arm, phase II, multicentre clinical trial to determine 
the rate of durable clinical benefit (DCB) of nivolumab in patients with 
class II expressing microsatellite stable colorectal cancer (MSS CRC). 
Objectives 
Primary objective: 
To detect the rate of durable clinical benefit in patients with class II 
expressing MSS CRC treated with single agent nivolumab, to justify 
further investigation in subsequent studies. 
Secondary objectives: 
To evaluate the benefit of single agent nivolumab to patients with class II 
expressing MSS CRC in terms of other clinical outcomes relating to 
tumour response and progression-free and overall survival time. 
Exploratory objective: 
To discover possible biomarkers for the prediction of a response to 
treatment with nivolumab. 
To investigate whether CD8+ and PD-1 T cells are supplementary 
biomarkers of response to treatment with nivolumab. 
Outcome 
Measures 
Primary outcome: 
• Durable clinical benefit  
Secondary outcomes: 
• Objective response 
• Best percentage change in sum of target lesion diameters (PCSD) 
• Time to maximal response 
• Progression-free survival time 
• Overall survival time 
Patient 
Population 
Patients with locally advanced or metastatic MSS CRC with class II 
expression 
Sample Size 
36 patients 
Key Inclusion 
Criteria (refer to 
section 4.1) 
 
• Histologically confirmed locally advanced or metastatic MSS CRC with 
class II expression 
• Patients must have completed all standard of care therapy that the 
treating oncologist deems appropriate. Trial treatment as first line 
therapy is permitted if the patient has declined standard of care therapy. 
• Age ≥ 18 years 
• Eastern Cooperative Oncology Group (ECOG) performance status 0-2 
• CT scan of chest, abdomen, pelvis within 28 days of registration 
demonstrating uni-dimensionally measurable disease as per RECIST 
version 1.1 
• Adequate haematological function: 
o Platelet count ≥100 x 109 /L 
o Neutrophils ≥1.5 x 109/L 
o Haemoglobin ≥ 90 g/L 
• Adequate renal function 

 
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ANICCA Protocol v7.0 01-Nov-2021 
 
o Creatinine <1.5 x Upper Limit of Normal (ULN) and >30 ml/min (as 
per institutional standard).  
• Adequate hepatic function: 
o Serum bilirubin ≤1.5 x upper limit of normal (ULN) 
o Serum AST or ALT ≤2.5 x ULN or <5 x ULN in the presence of 
liver metastases  
• Written informed consent 
Key Exclusion 
Criteria (refer to 
section 4.2) 
• Prior treatment with PD1/PDL1 inhibitors.  
• Untreated symptomatic brain or leptomeningeal metastatic disease. 
• Administration of chemotherapy, radioactive or biological cancer 
therapy within 4 weeks prior to the first dose of trial therapy. 
• Patient has not recovered to NCI Common Terminology Criteria for 
Adverse Events (CTCAE) grade 1 or better from the Adverse Event 
(AE) due to cancer therapeutics administered more than 4 weeks 
earlier. 
• Active autoimmune disease that has required systemic treatment in 
past 2 years. 
• Diagnosis of immunodeficiency or receiving systemic steroid therapy or 
any other form of immunosuppressive therapy within 7 days prior to the 
first dose of trial treatment. 
• At risk of bowel obstruction or bowel perforation. 
• History of tuberculosis, non-infectious pneumonitis, active pneumonitis  
• Known history of other malignancy, unless confirmation of potentially 
curative therapy with no evidence of disease for 3 years. 
• Positive for HIV, Hepatitis B or C. 
• Has had a live vaccine within 30 days of prior to first dose of trial 
treatment. 
Trial Treatment 
Nivolumab intravenous infusion, 480mg flat dose over 60 minutes, every 
4 weeks 
Trial Duration 
18 months recruitment, up to two years treatment, all patients will be 
followed up for a minimum of 18 months after registration. 
Sample 
Collection 
• Germline DNA cycle 1, day 1 pre-infusion 
• ctDNA, Cytokine/Chemokine Panel and proteomics cycle 1, day 1 pre-
infusion followed by every alternate cycle from cycle 3 onwards e.g. 
cycle 3, 5, 7 etc. (approx. every 8 weeks) 
ANICCA-Class II 
Trial Office 
Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer & 
Genomic Sciences, University of Birmingham, Edgbaston, Birmingham. 
B15 2TT 
 0121 414 6754 
 ANICCA-Class II@trials.bham.ac.uk 
Sponsor 
University of Birmingham 
 
 
 

 
Page ix 
 
ANICCA Protocol v7.0 01-Nov-2021 
 
TRIAL SCHEMA 
Figure 1 Trial Schema 
 

ANICCA-Class II Protocol 
 
Page x 
 
ANICCA Protocol v7.0 01-Nov-2021 
 
Figure 2 Screening Schema 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* If MS status is determined locally central testing is not required. Please ensure the pathology report 
which is sent with the biopsy sample confirms patient is Microsatellite Stable (MSS) and details RAS 
mutation testing results.  
Approach patient to discuss Microsatellite (MS) Status and Class II 
expression screening and provide patient with MS Status and Class 
II expression screening PIS 
Take consent from patient for MS Status and Class II expression 
testing 
Collect and send tumour sample (with completed screening biopsy 
form and diagnostic pathology report*) to central lab at Queen 
Elizabeth hospital Birmingham for testing 
Patient has Microsatellite Stable (MSS) class II 
expression and is therefore eligible for further 
trial screening 
Take consent from patient for trial 
Discuss trial with patient and provide trial PIS 
Patient does not have Microsatellite Stable (MSS) 
Class II expression and is therefore ineligible for 
further trial screening 
Perform screening assessments for trial entry 
Patient meets eligibility criteria 
Use the ANICCA Class II eRDC to 
register patient for trial entry 
Patient does not meet eligibility criteria and 
therefore cannot enter trial 
MS Status and Class II Expression Screening 
Main Trial Screening 
Trial office informs site of result within 10 working days of sample 
receipt 
Identify patient with locally advanced or metastatic colorectal 
cancer who would be potentially suitable for clinical trial entry 
Use the ANICCA Class II eRDC to register the patient for MS status 
and Class II expression testing 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
SCHEDULE OF EVENTS 
Table 1 Schedule of Events 
 
Microsatellite 
Status and 
Class II 
Expression 
Screening * 
Screening 
TRIAL ENTRY 
Treatment 
Follow up 
Within 28 
days of 
registration 
* 
Within 7 
days of 
registration 
* 
Day 1, 
cycle 
1* 
Day 1,  
Every cycle 
(every 4 
weeks) +/- 3 
days * 
Every alternate 
cycle from cycle 
3 onwards  
(approx. every 8 
weeks) +/- 3 days 
Every 9 
weeks 
Every 12 
weeks 
Treatment 
discontinu
ation visit  
(end of 
treatment) 
Safety follow 
up visit  
(28 days post 
treatment 
discontinuation
)21 
Every 4 
weeks for 
6 months 
then every 
12 weeks 
 
 
 
 
 
 
 
 
 
 
 
 
Informed consent1 
x 
x 
 
 
 
 
 
 
 
 
 
Archival diagnostic tumour biopsy sample for 
Class II and MS testing2 
x 
 
 
 
 
 
 
 
 
 
 
Demographics/Medical History/Prior 
Medications3 
 
x 
 
 
 
 
 
 
 
 
 
Vital Signs4 
 
 
x 
x 
x 
 
 
 
x 
x 
 
Physical Examination (including weight) 
 
 
x 
x 
x 
 
 
 
x 
x 
 
ECOG performance status5 
 
 
x 
x 
x 
 
 
 
x 
x 
 
Review Concomitant Medications6 
 
 
x 
x 
x 
 
 
 
x 
x 
 
Review Adverse Events7 
 
 
x 
x 
x 
 
 
 
x 
x 
x 
Full blood count (FBC)8 
 
 
x 
x 
x 
 
 
 
x 
x 
 
Comprehensive serum chemistry panel8 
 
 
x 
x 
x 
 
 
 
x 
x 
 
Urinalysis 
 
 
x 
 
 
 
 
 
x 
 
 
Coagulation parameters9 
 
x 
 
 
 
 
 
 
x 
 
 
HIV, Hepatitis B and C10 
 
x 
 
 
 
 
 
 
 
 
 
Pregnancy Test –Serum β-HCG11 
 
 
x 
 
 
 
 
 
 
 
 
Pregnancy Test – Urine12 
 
 
 
x 
x 
 
 
 
 
 
 
Renal function – GFR13 
 
 
x 
 
 
 
 
 
 
x 
 
Thyroid function and cortisol14 
 
 
x 
 
x 
 
 
 
x 
x 
 
Cytokine/Chemokine Panel and proteomics15 
 
 
 
x 
 
x 
 
 
x 
 
 
Germline DNA16 
 
 
 
x 
 
 
 
 
 
 
 
ctDNA17 
 
 
 
x 
 
x 
 
 
x 
 
 
CT scan with contrast (chest, abdomen, 
pelvis)18 
 
x 
 
 
 
 
x 
(up to 45 
weeks) 
x 
(after 45 
weeks) 
 
 
X 
(see notes) 
Nivolumab administration19 
 
 
 
x 
x 
 
 
 
 
 
 
Survival assessment20 
 
 
 
 
 
 
 
 
x 
x 
x 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Notes 
* 
Where applicable and acceptable in accordance to local practices, visits/assesments may be performed by telephone or video call. 
1. 
Written informed consent must be obtained prior to testing patient’s biopsy for MSS/Class II status and then further informed consent prior to any protocol 
specific procedure and within 28 days to starting treatment. 
2. 
The minimum requirement for a biopsy sample must be five slides of stained sections from formaldehyde fixed paraffin embedded (FFPE) tissue, or 
preferably representative blocks of tumour tissue. Cytology samples will also be accepted if a formalin fixed clot is available. For patients who have already 
had their MS status determined as MSS ensure pathology report confirming this is sent with their tumour biopsy sample. RAS testing results need to be 
provided on the pathology report sent with the biopsy sample.  
3. 
Includes smoking and alcohol history, any relevant significant medical conditions (other than colorectal cancer) and autoimmune conditions, history of 
treatment for the primary diagnosis, prior systemic treatment, radiation treatment and surgical treatment, including best response to prior treatments where 
applicable. Date of last prior cancer treatment must be documented and must not be within 4 weeks of registration. 
4. 
Vital signs to include: temperature, pulse, respiratory rate and blood pressure (average of 3 BP readings). Do not need repeating on day 1 of cycle 1 if 
performed within 7 days of intended IMP administration date. 
5. 
For ECOG performance status criteria see Appendix 1. Do not need repeating on day 1 of cycle 1 if performed within 7 days of intended IMP administration 
date. 
6. 
Concomitant medications taken within four weeks prior to registration should be recorded at baseline. Do not need repeating on day 1 of cycle 1 if performed 
within 7 days of intended IMP administration date. 
7. 
Adverse Events (AEs) and laboratory safety measurements will be graded per NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
v4.03 (see Appendix 2). All adverse events, whether gradable by CTCAE or not, will also be evaluated for seriousness. In addition to AE review at each 
cycle, extra safety monitoring will be performed at monthly intervals up to 6 months after treatment discontinuation. During follow-up, AE review can be 
performed via telephone call. If at the 6 month follow up review there are any toxicities at grade 2 or higher that the investigator considers to be related to 
the trial treatment then these should be followed up until they have reduced to grade 1 or less. Do not need repeating on day 1 of cycle 1 if performed within 
7 days of intended IMP administration date. 
8. 
Routine laboratory tests (e.g., Full blood count (FBC); comprehensive serum chemistry panel; urinalysis) will be performed by the local trial site laboratory 
or their contract laboratory. FBC to include: white blood cells, haematocrit, haemoglobin, platelets, neutrophils, lymphocytes, red blood cells, monocytes, 
basophils, eosinophils, absolute neutrophil count and serum chemistry to include: sodium, potassium, urea nitrogen, creatinine, magnesium, calcium (total), 
bilirubin (total), direct bilirubin, albumin, alkaline phosphatase (ALP), aspartate transferase (AST), alanine transferase (ALT), glucose, lactate 
dehydrogenase (LDH), phosphate, total protein, C reactive protein (CRP), Carcinoembryonic antigen (CEA). Routine laboratory tests may be performed up 
to 3 days prior to treatment administration visit. Do not need repeating on day 1 of cycle 1 if performed within 7 days of intended IMP administration date. 
Where applicable and acceptable in accordance to local practices, blood tests can be performed locally in GP surgeries or in community based clinics. 
9. 
Prothrombin (PT) / International Normalised Ratio (INR) and partial thromboplastin (aPTT) should be collected at screening and at Treatment 
Discontinuation Visit. Coagulation parameters should be determined throughout the trial when clinically indicated. 
10. 
Testing will be performed by the local laboratory at screening. Include Hepatitis C Virus (HCV) RNA (qualitative), Hepatitis B surface Antigen (HBsAg), and 
Human Immunodeficiency Virus (HIV) 1/2 antibodies. 
11. 
Women of a child bearing potential must have a negative serum pregnancy test prior to registration, this must be performed within 7 days of patient 
registration.  

 
Page xiii 
 
ANICCA Protocol v7.0, 01-Nov-2021 
 
12. 
Women of a child bearing potential must have a negative serum or urine pregnancy test (Minimum sensitivity 25 IU/L or equivalent units of HCG) this should 
be performed before the first IMP administration and then at every cycle before IMP administration (approx.. 4 weeks) i.e before cycle 1, cycle 2, cycle 3 
etc.  
13. 
To be eligible for trial entry patients must have adequate renal function as defined by Creatinine <1.5 x ULN and creatinine clearance >30 ml/min (calculated 
as per institutional standard). NOTE: An isotopic eGFR (Estimated Glomerular Filtration Rate )should only be perfomed if the result of the calculated eGFR 
is borderline to prevent exclusion of patients with a borderline value that is still acceptable for trial entry.  
14. 
Analysis of cortisol, T3, T4 and Thyroid Stimulating Hormone (TSH) will be performed by the local site laboratory. During treatment, testing will be performed 
at every cycle (approx. every 4 weeks), at Treatment Discontinuation Visit and at Safety Follow up Visit (28 days post treatment discontinuation). 
15. 
Collected before start of infusion at cycle 1 followed by every alternate cycle from cycle 3 onwards e.g. cycle 3, 5, 7 etc. and at Treatment Discontinuation 
Visit. Processing and storage of blood samples are to be carried out as described in ANICCA-Class II Laboratory Manual.  
16. 
Collected before start of infusion at cycle 1. 
17. 
Collected before start of infusion at cycle 1, followed by every alternate cycle from cycle 3 onwards e.g. cycle 3, 5, 7 etc. and at Treatment Discontinuation 
Visit. Processing and storage of blood samples are to be carried out as described in ANICCA- Class II Laboratory Manual.  
18. 
Tumour imaging by CT with contrast (chest, abdomen, pelvis) will be performed within 28 days prior to registration. The same imaging technique has to be 
used in a patient throughout the trial. Scans will be reported by RECIST 1.1 (Appendix 3). Tumour imaging will be performed every 9 weeks from treatment 
commencement (C1D1) up to 45 weeks and following this every 12 weeks until disease progression. Hyperprogression must be assessed where a patient 
has discontinued due to progressive disease. Hyperprogressive disease (HPD) in patients is defined as disease progression by RECIST criteria with a ≥2-
fold increase in the tumour growth rate during the treatment period versus the reference period with this being the tumour growth before treatment. Patients 
may initially show evidence of disease progression as a response to immunotherapy therefore patients may be allowed to continue treatment beyond 
RECIST defined disease progression if they are clinically stable and tolerating therapy. Trial treatment must then be discontinued upon further progression 
defined as the presence of any new lesion or an additional 10% increase in existing tumour burden from time of the initial progression .Following treatment 
discontinuation if patient has stopped trial treatment without progressive disease they should continue to be scanned according to this schedule until 
progressive disease is identified. NOTE. In this situation, it is important if treatment is discontinued earlier than 45 weeks from commencement of treatment, 
scans should continue to be performed every 9 weeks until this time point or disease progression. If disease progression has not been identified at 45 week 
scan then scans should continue to be performed every 12 weeks until disease progression or end of follow up. If patient discontinues without progressive 
disease after 45 weeks from commencement of treatment they should have scans every 12 weeks until disease progression. Response status will be 
assessed by the trial site. 
19. 
First administration of nivolumab should be given within 7 days of registration.  
20. 
Follow up will be completed every 4 weekly for 6 months then 12 weekly thereafter to obtain further treatment details and overall survival status. 
21. 
For patients who begin another cancer therapy within 28 days after discontinuation of study therapy, the Safety Follow-Up Visit should occur prior to the 
patient receiving another cancer therapy. 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
ABBREVIATIONS 
AE 
Adverse Event 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
ANC 
Absolute neutrophil count 
AR 
Adverse Reaction 
AST 
Aspartate transaminase 
CD4+ 
Cluster of differentiation 4 
CD8+ 
Cluster of differentiation 8 
CIITA 
Class II major histocompatibility complex transactivator 
CIRC 
Co-ordinated Immune Response Cluster 
CR 
Complete Response 
CRCTU 
Cancer Research UK Clinical Trials Unit 
CRC 
Colorectal cancer 
CRF 
Case Report Form 
ctDNA 
Circulating Tumour DNA 
CT 
Computerised Tomography 
CTCAE 
NCI Common Terminology Criteria for Adverse Events 
CTLA4 
Cytotoxic T-Lymphocyte Associated Protein 4 
CTLs 
Cytotoxic T Lymphocytes 
DCB 
Durable Clinical Benefit 
DILI 
Drug Induced Liver Injury 
DLT 
Dose Limiting Toxicity 
DNA 
Deoxyribonucleic Acid 
ECOG 
Eastern Cooperative Oncology Group 
EORTC 
European Organisation for Research and Treatment of Cancer 
eRDC 
Electronic Remote Data Capture 
FBC 
Full Blood Count 
FFPE 
Formalin fixed paraffin embedded 
FSH 
Follicle-Stimulating Hormone 
GCP 
Good Clinical Practice 
GFR 
Glomerular Filtration Rate 
GP 
General Practitioner 
Hb 
Haemoglobin 
HBsAg 
Hepatitis B antigen 
HCV 
Hepatitis C Virus 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HPD 
Hyperprogressive disease 
HRA 
Health Research Authority 
HuMAb 
Human Monoclonal Antibody 
IB 
Investigator Brochure 
IFN-γ 
Interferon gamma 
IgG4 
Immunoglobulin G4 
IHC 
Immunohistochemistry 
IMP 
Investigational Medicinal Product 
INR 
International Normalised Ratio 
irAE 
Immune-related Adverse Event 
ISF 
Investigator Site File 
IV 
Intravenous 
KCO 
Transfer coefficient measure 
LMWH 
Low Molecular Weight Heparin 
LVEF 
Left Ventricular Ejection Fraction 
MDT 
Multi-Disciplinary Team 

 
Page xv 
 
ANICCA Protocol v7.0, 01-Nov-2021 
 
MHC 
Major histocompatibility complex 
MHRA 
Medicines and Healthcare products Regulatory Agency 
MSI 
Microsatellite instability 
MS 
Microsatellite 
MSS 
Microsatellite stable 
MTD 
Maximum Tolerated Dose 
NSCLC 
Non-Small Cell Lung Cancer 
NHS 
National Health Service 
NYHA 
New York Heart Association 
OR 
Objective Response 
ORR 
Objective Response Rate 
OTC 
Over The Counter 
PD 
Progressive Disease 
PD-1 
Programmed cell Death protein 1 
PDL-1 
Programmed Death Ligand 1 
PFS 
Progression Free Survival 
PO 
By mouth 
PPK 
Population Pharmacokinetics  
PR 
Partial Response 
PS 
Performance Status 
PT 
Prothrombin 
QTc 
Corrected QT interval 
REC 
Research Ethics Committee 
RECIST 
Response Evaluation Criteria in Solid Tumours 
RNA 
Ribonucleic acid 
RCC 
Renal Cell Cancer 
RT 
Radiotherapy 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Serious Adverse Reaction 
SD 
Stable Disease 
SPC 
Summary of Product Characteristics  
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
T3 
Total Triiodothyronine 
T4 
Free Thyroxine 
TBX21 
T-box transcription factor 21 
TH1 
T Helper 1 cells 
TMG 
Trial Management Group 
TNO 
Trial Number 
TSH 
Thyroid Stimulating Hormone 
ULN 
Upper Limit of Normal 
 

 
Page 1 
 
ANICCA Protocol v7.0, 01-Nov-2021 
 
TABLE OF CONTENTS 
 
 
BACKGROUND AND RATIONALE ........................................................................................ 4 
1.1 
BACKGROUND ............................................................................................................................ 4 
1.2 
TRIAL RATIONALE ....................................................................................................................... 6 
1.2.1 
RATIONALE FOR DESIGN ................................................................................................ 6 
1.2.2 
RATIONALE FOR PATIENT POPULATION ...................................................................... 6 
1.2.3 
CHOICE OF TREATMENT ................................................................................................. 7 
1.2.4 
RATIONALE FOR DOSE .................................................................................................... 7 
1.2.5 
RATIONALE FOR INFUSION TIME ................................................................................... 7 
 
AIMS, OBJECTIVES AND OUTCOME MEASURES ............................................................. 8 
2.1 
OBJECTIVES ........................................................................................................................... 8 
2.1.1 
PRIMARY OBJECTIVE ....................................................................................................... 8 
2.1.2 
SECONDARY OBJECTIVES .............................................................................................. 8 
2.1.3 
EXPLORATORY OBJECTIVE ............................................................................................ 8 
2.2 
OUTCOME MEASURES .......................................................................................................... 8 
2.2.1 
PRIMARY OUTCOME MEASURE ..................................................................................... 8 
2.2.2 
SECONDARY OUTCOME MEASURE ............................................................................... 8 
 
TRIAL DESIGN ........................................................................................................................ 8 
 
ELIGIBILITY ............................................................................................................................ 9 
4.1 
INCLUSION CRITERIA ................................................................................................................... 9 
4.2 
EXCLUSION CRITERIA .................................................................................................................. 9 
 
INFORMED CONSENT AND SCREENING .......................................................................... 11 
5.1 
INFORMED CONSENT ................................................................................................................. 11 
5.1.1 
REMOTE CONSENT ........................................................................................................ 12 
5.2 
SCREENING .............................................................................................................................. 12 
5.2.1 
STAGE 1: MS STATUS AND CLASS II EXPRESSION SCREENING ............................. 12 
5.2.2 
STAGE 2: TRIAL SCREENING ........................................................................................ 13 
5.2.3 
SCREENING LOG ............................................................................................................ 14 
 
TRIAL ENTRY ....................................................................................................................... 15 
6.1 
PATIENT REGISTRATION ............................................................................................................ 15 
 
TREATMENT DETAILS......................................................................................................... 16 
7.1 
TRIAL TREATMENT .............................................................................................................. 16 
7.1.1 
DESCRIPTION OF INVESTIGATIONAL MEDICINAL PRODUCT (IMP)......................... 16 
7.1.2 
INVESTIGATIONAL MEDICINAL PRODUCT SUPPLY AND LABELLING...................... 16 
7.1.3 
NIVOLUMAB ADMINISTRATION ..................................................................................... 16 
7.1.4 
DRUG ACCOUNTABILITY ............................................................................................... 16 
7.2 
TREATMENT SCHEDULE ............................................................................................................. 16 
7.3 
ASSESSMENTS .................................................................................................................... 17 
7.3.1 
ON-TREATMENT.............................................................................................................. 17 
7.3.2 
TREATMENT DISCONTINUATION VISIT (END OF TREATMENT) ............................... 18 
7.3.3 
SAFETY FOLLOW UP VISIT ............................................................................................ 18 
7.3.4 
FOLLOW UP ..................................................................................................................... 19 
7.4 
SAMPLE COLLECTION ......................................................................................................... 19 
7.4.1 
BLOOD COLLECTION ..................................................................................................... 19 
7.4.2 
TRANSLATIONAL SAMPLES .......................................................................................... 19 
7.5 
DOSE MODIFICATION AND TOXICITY MANAGEMENT ..................................................... 20 
7.6 
TREATMENT COMPLIANCE ................................................................................................ 25 
7.7 
CONCOMITANT MEDICATION ............................................................................................. 25 
7.7.1 
ACCEPTABLE CONCOMITANT MEDICATIONS ............................................................ 25 
7.7.2 
PROHIBITED CONCOMITANT MEDICATIONS .............................................................. 25 
7.8 
CONTRACEPTION ................................................................................................................ 26 
7.8.1 
WOMEN OF CHILDBEARING POTENTIAL ..................................................................... 26 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
7.8.2 
MALES .............................................................................................................................. 26 
7.9 
PROGRESSION AND DEATH ....................................................................................................... 26 
7.10 
TRIAL TREATMENT DISCONTINUATION AND WITHDRAWAL OF CONSENT ....................................... 27 
7.10.1 DISCONTINUATION OF INVESTIGATIONAL MEDICINAL PRODUCT .......................... 27 
7.10.2 WITHDRAWAL OF CONSENT ......................................................................................... 27 
 
COVID 19 PANDEMIC ........................................................................................................... 27 
 
TRANSLATIONAL RESEARCH ........................................................................................... 28 
 
ADVERSE EVENT REPORTING .......................................................................................... 29 
10.1 
REPORTING REQUIREMENTS ..................................................................................................... 29 
10.1.1 ADVERSE EVENTS ......................................................................................................... 29 
10.1.2 LABORATORY TEST ABNORMALITIES ......................................................................... 29 
10.1.3 DRUG INDUCED LIVER INJURY (DILI) EVENTS ........................................................... 29 
10.1.4 SERIOUS ADVERSE EVENTS ........................................................................................ 29 
10.1.5 MONITORING PREGNANCIES FOR POTENTIAL SERIOUS ADVERSE EVENTS ...... 30 
10.1.6 REPORTING PERIOD ...................................................................................................... 30 
10.2 
REPORTING PROCEDURE .......................................................................................................... 30 
10.2.1 REPORTING PROCEDURES FOR SITE ........................................................................ 30 
10.2.2 ANICCA-CLASS II TRIAL OFFICE ................................................................................... 31 
10.2.3 REPORTING TO THE COMPETENT AUTHORITY AND RESEARCH ETHICS 
COMMITTEE ................................................................................................................................. 31 
10.2.4 INVESTIGATORS ............................................................................................................. 31 
10.2.5 TRIAL STEERING COMMITTEE ...................................................................................... 32 
10.2.6 MANUFACTURER OF INVESTIGATIONAL MEDICINAL PRODUCT ............................. 32 
 
DATA HANDLING AND RECORD KEEPING ...................................................................... 33 
11.1 
DATA COLLECTION ................................................................................................................... 33 
11.2 
ARCHIVING ............................................................................................................................... 35 
 
QUALITY MANAGEMENT .................................................................................................... 36 
12.1 
SITE SET-UP AND INITIATION ..................................................................................................... 36 
12.2 
ON-SITE MONITORING ............................................................................................................... 36 
12.3 
CENTRAL MONITORING ............................................................................................................. 36 
12.4 
AUDIT AND INSPECTION ............................................................................................................. 36 
12.5 
NOTIFICATION OF SERIOUS BREACHES ...................................................................................... 36 
 
END OF TRIAL DEFINITION ................................................................................................ 37 
 
STATISTICAL CONSIDERATIONS ...................................................................................... 38 
14.1 
DEFINITION OF OUTCOME MEASURES ........................................................................................ 38 
14.1.1 PRIMARY OUTCOME MEASURE ................................................................................... 38 
14.1.2 SECONDARY OUTCOME MEASURES .......................................................................... 38 
14.2 
ANALYSIS OF OUTCOME MEASURES .......................................................................................... 38 
14.3 
PLANNED INTERIM ANALYSES .................................................................................................... 39 
14.4 
PLANNED FINAL ANALYSES ....................................................................................................... 39 
14.5 
SAMPLE SIZE ........................................................................................................................... 39 
 
TRIAL ORGANISATIONAL STRUCTURE ........................................................................... 40 
15.1 
SPONSOR ................................................................................................................................ 40 
15.2 
COORDINATING CENTRE ........................................................................................................... 40 
15.3 
TRIAL MANAGEMENT GROUP (TMG) ......................................................................................... 40 
15.4 
TRIAL STEERING COMMITTEE (TSC) ......................................................................................... 40 
15.5 
FINANCE .................................................................................................................................. 40 
 
ETHICAL CONSIDERATIONS .............................................................................................. 41 
 
CONFIDENTIALITY AND DATA PROTECTION .................................................................. 41 
 
INSURANCE AND INDEMNITY ............................................................................................ 42 
 
PUBLICATION POLICY ........................................................................................................ 42 

 
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REFERENCE LIST ................................................................................................................ 43 
 
EASTERN COOPERATIVE ONCOLOGY GROUP PERFORMANCE (ECOG) 
STATUS26 
45 
 
COMMON TOXICITY CRITERIA GRADINGS .......................................................... 45 
 
RECIST V1.1 CRITERIA ........................................................................................... 46 
 
DEFINITION OF ADVERSE EVENTS ...................................................................... 49 
 
WMA DECLARATION OF HELSINKI....................................................................... 51 
 
MANAGEMENT OF TOXICITIES ............................................................................. 54 
 
LIST OF TABLES 
Table 1 Schedule of Events ................................................................................................... xi 
Table 2 Dosing instructions for nivolumab ............................................................................16 
Table 3 Dose modification and toxicity management guidelines for immune-related AEs 
associated with nivolumab ....................................................................................................21 
Table 4 Case Report Form ...................................................................................................33 
Table 5 ECOG ......................................................................................................................45 
Table 6 Evaluation of Target Lesions ...................................................................................47 
Table 7 Evaluation of Non-target Lesions .............................................................................47 
Table 8 Overall Response evaluation ...................................................................................48 
 
LIST OF FIGURES 
Figure 1 Trial Schema ........................................................................................................... ix 
Figure 2 Screening Schema ................................................................................................... x 
Figure 3 Relationship between CIRC expression and mean HLA DR/DP/DQ expression in the 
TCGA .................................................................................................................................... 5 
 

 
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BACKGROUND AND RATIONALE 
 
1.1 
BACKGROUND 
Immuno-oncology is transforming the care of certain patients with cancer. Not all patients 
respond to these therapies however, and in some common cancers checkpoint blockade has 
failed to make any real impact. In 2014 there were over 41,000 new cases of colorectal cancer 
(CRC) in the UK and nearly 16,000 deaths from the disease, making it the second commonest 
cause of cancer death (Cancer Research UK Cancer Statistics Key Facts). 15% of patients 
with CRC develop it as a result of deficient mismatch repair (microsatellite instability – MSI): 
this cohort of patients respond well to PD-1/PD-L1 blockade as these tumours harbour a very 
high number of mutations thus increasing the likelihood of the presence of immunogenic neo-
epitopes which elicit an immune response1. The majority of CRC patients, particularly those 
with metastatic disease (around 95%), do not display this hyper-mutator phenotype 
(microsatellite stable (MSS) CRC) and in these patients the results of PD-1/PD-L1 blockade 
have been disappointing1. 
 
It is now recognised that not all MSS CRC are immunologically impoverished. We recently 
described a 28-gene T helper cell 1 (Th1)-centric immune metagene, the co-ordinated immune 
response cluster (CIRC) 2, which readily distinguished MSI CRC (with high CIRC expression) 
from MSS cancers (with significantly lower CIRC expression). However, around 10-15% of 
MSS patients have CIRC expression similar to MSI-high patients, thus suggesting the 
existence of a group of MSI-like MSS CRC patients and this was not a group with an unusually 
high mutational burden. 
 
The CIRC is highly significantly correlated with key discrete immune cell subset signatures, in 
particular the Th1 cell and cytotoxic cell signatures3, in spite of little overlap in the gene sets4, 
underlying its validity as a measure of the strength of microenvironmental immunity. We have 
also shown that TH1 CIRC highly correlates with the immunoscorecomputerised data. Th1 
cells recognise peptides expressed on cancer cells in association with MHC class II molecules. 
Th1 cells maintain CD8+ T cell number, the function of antigen-specific cytotoxic T 
lymphocytes (CTLs) and enhance intra-tumoral CTL trafficking5-7. They are major mediators of 
immunological tumour cell death8,9 and adoptive transfer approaches involving autologous 
CD4+ T cells have resulted in durable responses10,11. Class II expression is prognostic in CRC 
and associated with the presence/absence of metastases12. Importantly, the majority of 
immunogenic mutated neo-epitopes are class II restricted and recognised by CD4+ cells13.  
 
The CIRC contains 9 separate class II genes. We asked whether high class II expression might 
be a surrogate for high CIRC expression which characterises the MSI-like MSS samples by 
analysing the relationship between CIRC expression and mean HLA DR/DP/DQ expression 
(Figure 3). As expected, mean expression of these HLA genes is highly correlated with the 
CIRC (Pearson = 0.856) and revealed that a high proportion of the top 10% and top 15% of 
MSS high CIRC-expressing patients are in the top 10 or 15% of class II gene expression. Thus 
high class II expression correlates very closely with CIRC expression.  

 
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Figure 3 Relationship between CIRC expression and mean HLA DR/DP/DQ expression 
in the TCGA 
 
The pivotal role of class II expression in driving microenvironmental immunological reactivity 
was demonstrated in studies where the master class II transcriptional activator (CIITA) was 
transfected into poorly immunogenic class II negative cancer cell lines (but which expressed 
class I)14,15. Unlike parental cells, most CIITA transfectants failed to grow. Immunological 
memory was established in animals receiving CIITA transfectants; parental cell re-challenge 
was rejected. CIITA transfected cancer cells developed robust antigen processing function and 
tumours formed by CIITA transfected cells were massively infiltrated by both CD4+ and CD8+ 
T cells. In melanoma tumour membrane class II negative patients had lower response rate, 
progression free survival (PFS) and overall survival (OS) when treated with PD-1/PD-L1 
blockade than Class II positive patients: Class I expression and T cell density were not 
significantly predictive16. Furthermore, there is in vitro data that PD-L1 blockade enhances 
Th1-mediated cytotoxicity only against cancer cells that express high levels of class II 
expression17. Recently, class II expression on Hodgkin Reed-Sternberg cells, has emerged as 
a key predictive biomarker of response to checkpoint blockade in Hodgkin’s disease18.  
 
It was originally planned that the criteria for nivolumab treatment in the trial would be >50% 
cancer cell staining for class II, as these MSS cancers immune-copied MSI cancers.  
With positivity defined as >50% cancer cell staining, a 10% positivity rate estimate was 
obtained from a large series of primary resections. Earlier data, again showing a strong class 
II positive rate (i.e. >50% cancer cell positivity) of around 10% in primary cancers, explored 
the prognostic impact of class II staining. In a Cox proportional model which included stage 
and microsatellite status the HR for strong DR expression versus none was 0.42 and 5 year 
survival in MSS patients with high class II expression was around 80%19. Thus, it is likely that 
the proportion of strong class II positive patients presenting with metastatic disease will be less 
than 10% simply due their good prognosis. This would be analogous to MSI cancers where 
these account for around 15% primary cases but only 3-4% metastatic cases because of their 
much better prognosis. 
In the most comprehensive analysis of the impact of MHC expression on outcome with 
checkpoint blockade in melanoma20, the expression of MHC class II was generally low with 

 
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around 30% of samples in 2 clinical trial datasets expressing >1% melanoma cell class II 
staining. This staining was concentrated at the invasive inflammatory margin consistent with 
local class II induction by IFNγ  produced by Th1 cells, the chief producers of IFNγ along with 
NK cells, and the expression of an IFNγ signatures was positively correlated with class II 
expression and the level of tumour-infiltrating T cells. Whereas class I levels had no predictive 
impact on outcome with single agent nivolumab (but was predictive for outcome with 
ipilimumab), >1% class II expression predicted for greater degrees of disease control: using 
the 1% threshold only 13% with high expression had PD as BOR compared with 46% with low 
expression. Class II expression using this threshold was not predictive of outcome with CTLA4 
blockade or dual nivolumab/ipilimumab, an important finding when considering the use of 
combination therapy in patients selected for checkpoint blockade therapy on the basis of class 
II expression: indeed, recent data suggests that the MHC-II+ phenotype drives immune escape 
via TIL up-regulation of LAG321. >1% expression was associated with better survival in those 
treated with nivolumab (HR=0.11, CI 0.02-0.83)20. Finally, as expected a number of IFNγ 
signatures were also associated with improved outcome with nivolumab but not with 
ipilimumab. Thus baseline levels of IFNγ and of class II induced on tumour cells by IFNγ 
predicted for significantly improved outcome with nivolumab and a threshold of >1% was 
sufficient to dichotomise patients by class II expression. Efficacy of anti-PD1 therapy was 
dependant on low level pre-existing IFNγ driven inflammation related to the recognition of 
neoantigen presented on cancer cells in association with class II by CD4+ T cells. Checkpoint 
blockade enables these CD4+ cells to produce more IFNγ and institute an amplification loop 
through the up-regulation of more class II (thus enhancing further antigen recognition and T 
cell activation and potentially naïve T cell priming22 and CXCL9/10 induction on tumour cells 
to facilitate T cell trafficking. Finally, the first study demonstrating the predictive power of class 
II expression in determining outcome with anti-PD1 therapy also used a low class II threshold 
(5%). The institution of a positive amplification loop will only be possible if some of the cancer 
cells can be induced to express class II by IFNγ, have a collection of microenvironmentally 
annotated organoids and even in the tumours with totally absent class II on whole sections the 
minimum inducible population is 25% and can be greater than 50% and in those with low (2-
3%) staining the majority of the cells can be induced (unpublished data). 
Thus, tumours stain with any degree of class II cancer cell positivity be considered for 
nivolumab therapy. It is important to note that the data we have generated on class II positivity 
rates in metastatic patients is itself an important outcome: it is now little surprise that the 
response rate in MSS CRC is so low, given that only approximately 10% of the cancers in the 
metastatic setting have class II staining indicative of a total lack of IFNγ the cancers which as 
mentioned can be induced to express class II by IFNγ. 
 
1.2 
TRIAL RATIONALE 
1.2.1 RATIONALE FOR DESIGN 
As a proof of concept trial, a single arm phase II design is adopted. MS status and Class II 
expression screening will be undertaken for 360 patients with the aim of identifying 36 patients 
with class II MSS CRC, assuming class II MSS rate of 10% in the population. The trial will use 
a Bayesian design to determine clinically relevant signal of effect in this population. 
 
1.2.2 RATIONALE FOR PATIENT POPULATION 
The majority of patients with locally advanced or metastatic CRC have tumours which exhibit 
microsatellite stability– MSS CRC and in these patients the results of PD-1/PD-L1 blockade 
have been disappointing. A proportion of these patients with class II expression demonstrate 
similarities to MSI CRC in terms of immunologically favourable microenvironment. These 
patients may receive more clinical benefit from PD-1 blockade than those with lower or 
negative class II expression. Clinical trials in melanoma support this hypothesis where tumour 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
membrane class II negative patients had lower response rate, PFS and OS when treated with 
PD-1/PD-L1 blockade than Class II positive patients. 
 
1.2.3 CHOICE OF TREATMENT 
Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody (HuMAb), which binds 
to the PD-1 receptor and blocks its interaction with PD-L1 and PD-L2. The PD-1 receptor is a 
negative regulator of T-cell activity that has been shown to be involved in the control of T-cell 
immune responses. Engagement of PD-1 with the ligands PD-L1 and PD-L2, which are 
expressed on antigen presenting cells and may be expressed by tumours or other cells in the 
tumour microenvironment, results in inhibition of T-cell proliferation and cytokine secretion. 
Nivolumab potentiates T-cell responses, including anti-tumour responses, through blockade of 
PD-1 binding to PD-L1 and PD-L2 ligands. In the pooled dataset of nivolumab 3 mg/kg as 
monotherapy across tumour types (n = 2578) with minimum follow-up ranging from 2.3 to 28 
months, the most frequent adverse reactions (≥ 10%) were fatigue (30%), rash (17%), pruritus 
(13%), diarrhoea (13%), and nausea (12%). The majority of adverse reactions were mild to 
moderate (Grade 1 or 2). 
 
The Checkmate 142 trial investigated nivolumab treatment in patients with MSI CRC that were 
intolerant of or progressed on one or more lines of previous therapy. The trial showed good 
responses in heavily pre-treated patients. PFS at 12 months was 48% with an overall response 
rate of 31%. Grade 3-4 treatment related adverse events occurred in 20% of patients, making 
it a well-tolerated treatment23. Nivolumab has now been licenced by the FDA for use in MSI-
CRC. 
 
1.2.4 RATIONALE FOR DOSE 
Based on modelling of dose/exposure efficacy and safety relationships, there are no clinically 
significant differences in efficacy and safety between a nivolumab dose of 240 mg every 2 
weeks or 3 mg/kg every 2 weeks. Additionally, based on these relationships, there were no 
clinically significant differences between a nivolumab dose of 480 mg every 4 weeks or 3 mg/kg 
every 2 weeks in adjuvant treatment of melanoma, advanced melanoma and advanced RCC24. 
The treatment schedule for the ANICCA Class II trial was previously 240mg every 2 weeks 
however as there is no clinically significant differences in efficacy and safety between a 
nivolumab dose of 240 mg every 2 weeks and a 480mg dose every 4 weeks, a decision was 
made to change the dosing of nivolumab to 480mg every 4 weeks. Treatment every 4 weeks 
is less demanding on patients. Following consultation with participating sites and Bristol Myers 
Squibb the nivolumab treatment schedule for with trial will now be 480 mg every 4 weeks.   
 
1.2.5 RATIONALE FOR INFUSION TIME 
With reference to the nivolumab Summary of Product Characteristics the recommended dose 
for Nivolumab is 240mg every 2 weeks over 30 minutes or 480mg every 4 weeks over 60 
minutes. It has been decided that the does should be 480mg over 60 minutes every 4 weeks. 
This would reduce the number of visits patients would have to attend clincis thorught out the 
trial which would ease the burden on them  in the treatment of Melanoma and Renal Cell 
Carcinoma  
.   
 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
AIMS, OBJECTIVES AND OUTCOME MEASURES 
 
2.1 
OBJECTIVES 
2.1.1 PRIMARY OBJECTIVE 
Detect the rate of durable clinical benefit in patients with class II expressing MSS CRC treated 
with single agent nivolumab, to justify further investigation in subsequent studies. 
 
2.1.2 SECONDARY OBJECTIVES 
Evaluate the benefit of single agent nivolumab to patients with class II expressing MSS CRC 
in terms of other clinical outcomes relating to tumour response and progression-free and 
overall survival time. 
 
2.1.3 EXPLORATORY OBJECTIVE 
To discover possible biomarkers for the prediction of a response to treatment with nivolumab. 
To investigate whether CD8+ and PD-1 T cells are supplementary biomarkers of response to 
treatment with nivolumab.  
 
2.2 
OUTCOME MEASURES 
2.2.1 PRIMARY OUTCOME MEASURE 
• Durable clinical benefit  
 
2.2.2 SECONDARY OUTCOME MEASURE 
• Objective response 
• Best percentage change in sum of target lesion diameters (PCSD) 
• Time to maximal response 
• Progression-free survival time  
• Overall survival time 
 
 
 
TRIAL DESIGN 
 
This is an open label, multi-centre, single arm phase II trial. Recruitment will take place over 
an 18 month period in which 36 MSS CRC patients with Class II expression will be registered 
to receive 4 weekly nivolumab infusions for up to two years, until progressive disease is 
identified or unacceptable toxicities occur. The trial will continue until all patients have been 
followed up for a minimum of 18 months after registration.  
 
 

 
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ELIGIBILITY 
 
4.1 
INCLUSION CRITERIA 
• Histologically confirmed locally advanced or metastatic MSS CRC with class II 
expression (greater than 1% cancer cell positivity for class II expression on 
immunohistochemistry). 
• Eastern Cooperative Oncology Group (ECOG) performance status 0-2 (APPENDIX 1)  
• Age ≥ 18 years 
• Patients must have completed all standard of care therapy that the treating oncologist 
deems appropriate. Trial treatment as first line therapy is permitted if the patient has 
declined standard of care therapy.  
• CT scan of chest, abdomen, pelvis within 28 days of registration demonstrating uni-
dimensionally measurable disease as per RECIST version 1.1 (APPENDIX 3). 
• Demonstrate adequate haematological function: 
o Platelet count ≥100 x 109 /L 
o Neutrophils ≥1.5 x 109/L 
o Haemoglobin ≥ 90 g/L 
• 
Demonstrate adequate hepatic function: 
o Serum bilirubin ≤1.5 x upper limit of normal (ULN) 
o Serum AST or ALT ≤2.5 x ULN or <5 x ULN in the presence of liver metastases  
• 
Demonstrate adequate renal function 
o Creatinine <1.5 times ULN and >30ml/min (as per institutional standard).  
• 
Provision of signed and dated, written informed consent prior to any trial specific 
procedures, sampling and analyses. 
• 
Negative pregnancy test (female patients of reproductive potential). (Serum Test must 
be negative) 
• 
Patients must agree to the use of contraception as detailed in section 7.8 
 
4.2 
EXCLUSION CRITERIA 
• Previous treatment with PD1/PDL1 inhibitors. 
• Untreated symptomatic brain or leptomeningeal metastatic disease. 
• Medical or psychiatric conditions compromising informed consent. 
• Any medical condition which, in the opinion of the Investigator, would compromise the 
ability of the patient to participate in the trial or which would jeopardise compliance with 
the protocol. 
• Administration of chemotherapy, radioactive or biological cancer therapy within 4 weeks prior 
to the first dose of trial therapy Patient has not recovered to CTCAE grade 1 or better from 
the Adverse Event (AE) due to cancer therapeutics administered more than 4 weeks 
earlier.  
• Active autoimmune disease that has required systemic treatment in past 2 years (i.e. 
with use of disease modifying agents, corticosteroids or immunosuppressive drugs). 
Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid replacement 
therapy for adrenal or pituitary insufficiency, etc.) is not considered a form of systemic 
treatment. 
• Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any 
other form of immunosuppressive therapy within 7 days prior to the first dose of trial 
treatment. Replacement therapy (e.g. thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form 
of systemic treatment. 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
• Patient has risk factors for bowel obstruction or bowel perforation (examples include but 
not limited to a history of acute diverticulitis, intra-abdominal abscess and abdominal 
carcinomatosis). 
• Patient has a known history of other malignancy, unless the patient has undergone 
potentially curative therapy with no evidence of that disease for 3 years. 
• Has a history of non-infectious pneumonitis requiring steroids or has active pneumonitis. 
• Female patients that are either pregnant or breast feeding.  
• Male and female patients (of childbearing age) not willing to use adequate contraception. 
• Patient previously had a severe hypersensitivity reaction to treatment with another 
monoclonal antibody. 
• Patient is positive for Human Immunodeficiency Virus (HIV) (HIV 1/2 antibodies), active 
Hepatitis B (HBsAg reactive) or Hepatitis C (HCV RNA (qualitative) is detected); patients 
with negative Hepatitis C antibody testing may not need RNA testing. Patients with 
evidence of Hepatitis B infection who are treated adequately with anti-viral therapy are 
deemed eligible. 
• Known history of tuberculosis.  
• Patient has an active infection requiring therapy. Patients with evidence of Hepatitis B 
infection but are being treated adequately with anti-viral therapy are deemed eligible. 
• Has received a live vaccine within 30 days prior to the first dose of trial treatment (see 
Section 7.7.2 for further details) 
• Patient is, at the time of signing informed consent, a regular user (including “recreational 
use”) of any illicit drugs or had a recent history (within the last year) of substance abuse 
(including alcohol). 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
INFORMED CONSENT AND SCREENING 
 
Patients attending the oncology clinic with histologically confirmed locally advanced or 
metastatic CRC and who in the Investigator’s opinion would be potentially suitable for trial entry 
will be approached to obtain consent for screening; this will be conducted as a two-stage 
process. Please refer to Figure 2 for an overview of the screening process for the trial. Full 
details are provided below.  
 
5.1 
INFORMED CONSENT 
It is the responsibility of the Investigator to obtain written informed consent for each patient 
prior to performing any trial related procedure. Patient Information Sheets (PIS) are provided 
to facilitate this process. Investigators must ensure that they adequately explain to the patient 
the aim, screening process, trial treatment, assessment schedule, anticipated benefits and 
potential hazards of taking part in the trial. The Investigator should also stress that the patient 
is completely free to refuse to take part or withdraw from the trial at any time without their 
medical care being affected. The patient should be given ample time (e.g. 24 hours) to read 
the Patient Information Sheet and to discuss their participation with others outside of the site 
research team. The patient must be given an opportunity to ask questions which should be 
answered to their satisfaction. The right of the patient to refuse to participate in the trial without 
giving a reason must be respected.  
 
If the patient expresses an interest in participating in the trial they should be asked to sign and 
date the latest version of the applicable Informed Consent Forms (ICF). The Investigator must 
then sign and date the form at the same time. A copy of Informed Consent Forms should be 
given to the patient, a copy should be filed in the hospital notes, and the original placed in the 
Investigator Site File (ISF). Once the patient is entered into screening, the patient’s trial number 
should be entered on Informed Consent Forms maintained in the ISF. In addition, if the patient 
has given explicit consent a copy of the signed Informed Consent Forms must be sent in the 
post to the ANICCA-Class II Trial Office for review. 
 
Details of the informed consent discussions should be recorded in the patient’s medical notes. 
This should include date of, and information regarding, the initial discussion, the date consent 
was given, the name of the trial and the version number and date of the Patient Information 
Sheet and Informed Consent Form that was provided. Throughout the trial, the patient should 
have the opportunity to ask questions about the trial and any new information that may be 
relevant to the patient’s continued participation should be shared with them in a timely manner. 
On occasions it may be necessary to re-consent the patient in which case the process above 
should be followed and the patient’s right to withdraw from the trial respected. 
 
Principle Investigators (PIs) must be consultants, but experienced oncologists, including 
Specialist Registrars (SpRs) may be Co-Investigators and permitted to consent patients, 
confirm patient eligibility and perform causality for SAEs and if delegated this duty by the PI. 
 
There are two types of PIS and ICF for the ANICCA-Class II Trial: 
1. 
Microsatellite (MS) Status and Class II Expression Screening PIS and ICF. This 
provides information regarding the testing of histological specimens for MS status (if 
not established locally) and Class II expression. 
2. 
Main Trial PIS and ICF 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Electronic and paper copies of the PIS and ICF are available from the ANICCA-Class II Trial 
Office and should be printed or photocopied onto the headed paper of the local institution. 
 
5.1.1 REMOTE CONSENT 
 
Remote Consent for both Microsatellite (MS) Status and Class II Expression screening and 
trial entry is permitted by telephone or video consultation instead of face-to-face consultations. 
In these circumstances, the appropriate PIS and ICF should be sent to the patient by post or 
email prior to the call, with adequate time to read the documents. The PIS and consent process 
is then discussed on the call between the investigator and the patient who then signs the form 
at the time of the call. 
 
The patient will then send the signed ICF back in the post where it is then signed by the 
consenting investigator. The dates of signing should therefore differ. Once the ICF has been 
received at site and signed by the investigator, the patient can then be registered for pre-
screening or trial entry via the eRDC system. The process of remote consent must be 
documented in the medical notes. Scanning the ICF is not permissible as the two wet 
signatures need to be on the same form. 
 
For patients consenting to trial entry the same process as above applies however, patients 
have the additional option of bringing the ICF to clinic to be signed by the consenting 
investigator on the day of their screening assesments. 
 
Remote consent is only permissible at sites where local procedures are in place and it is 
allowed according to trust policies. 
 
5.2 
SCREENING 
5.2.1 STAGE 1: MS STATUS AND CLASS II EXPRESSION SCREENING 
The patient should be provided with the MS status and Class II Expression Screening PIS at 
a clinic visit and, if willing to participate in stage 1 of the screening process, informed consent 
should be gained using MS status and Class II Expression ICF.  
Patients are registered for screening with the Cancer Research UK Clinical Trials Unit 
(CRCTU) at the University of Birmingham. Informed consent must be obtained prior to 
registration as described in section 5.1. Screening registration should be performed by sites 
using the ANICCA online Remote Data Capture (eRDC) system which has been developed by 
CRCTU.  
 
https://www.cancertrials.bham.ac.uk/ANICCAClassIILive 
 
At screening registration the patient will be given a unique Trial Number (TNO). The TNO will 
be used to identify the patient throughout the whole trial and should be recorded on any 
correspondence with the ANICCA-Class II Trial Office. The TNO should be documented on 
the original signed Informed Consent Form filed in the ISF. Additionally a copy should be sent 
to the ANICCA-Class II Trial Office for review. A copy of the screening registration report 
should be printed and filed in the ISF and in the patient’s medical records. 
In case of any problems with online screening registration, a paper Screening Registration 
Form should be completed. These details can be phoned through to the ANICCA-Class II Trial 
Office using the numbers below: 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
 
 
The patient’s archival tumour biopsy should be obtained, packaged and sent for central 
pathology testing as per the laboratory manual. The minimum requirement for a biopsy sample 
must be five slides of stained sections from formaldehyde fixed paraffin embedded (FFPE) 
tissue, or preferably representative blocks of tumour tissue. Cytology samples will also be 
accepted if a formalin fixed clot is available. If there is not enough tumour sample available to 
confirm class II expression, patients may need to have an additional biopsy. Samples should 
be sent to The Queen Elizabeth Hospital Birmingham (University Hospitals Birmingham NHS 
Foundation Trust), for central immunohistochemical testing at a nationally recognised 
Molecular Pathology Diagnostic Service for determination of MS status (if not established 
locally) and Class II status. A screening biopsy form should be completed and enclosed with 
the sample in addition to a copy of the patient’s pathology report confirming CRC diagnosis, 
RAS Mutation test results and MSS status (if applicable).  
 
The samples will be assessed by the central pathology team for MSS status (if applicable) and 
class II overexpression also referred to as class II expression. This is defined as more than 
1% of tumour cells showing membranous staining. Each sample should have at least 50 viable 
neoplastic cells overall to be assessed. If the result obtained is equivocal, the sample analysis 
will be repeated and reviewed by another member of the central pathology team. The ANICCA-
Class II Trial Office will inform sites of patient’s MSS (if applicable) and Class II status within 
10 working days of sample receipt. MSS and class II expression must be confirmed for the 
patient to be eligible for the trial.  
 
5.2.2 STAGE 2: TRIAL SCREENING 
Once MSS with Class II expression is confirmed by the ANICCA-Class II Trial Office, the 
patient should then attend a clinic visit to be given the PIS for the trial and if the patient wishes 
to participate obtain informed consent using the trial ICF.  
Trial treatment should commence within 28 days of consent, any deviation from this should be 
discussed with the ANICCA-Class II Trial Office in advance. 
 
If the patient consents, the following screening tests should be undertaken locally up to 28 
days prior to trial entry: 
• Full medical history - To include smoking and alcohol history, any relevant significant 
medical conditions (other than colorectal cancer) and autoimmune conditions, history of 
treatment for the primary diagnosis, including prior systemic treatment, radiation 
treatment and surgical treatment including best response to prior treatments where 
applicable. Date of last prior cancer treatment must be documented. Radiographic 
studies performed prior to trial entry may also be requested for review. 
• Coagulation parameters: Prothrombin (PT) / International Normalised Ratio (INR) and 
partial thromboplastin (aPTT) 
• CT scan with contrast – chest, abdomen and pelvis within 28 days of planned 
treatment date (RECIST v1.1 reporting – APPENDIX 3).  
In case of any problems with online registration, details can be 
phoned through on: 
 
 0121 414 6754 
09:00 to 17:00 GMT, Monday to Friday 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
• Hepatitis C Virus (HCV) RNA (qualitative), Hepatitis B Surface Antigen and Human 
Immunodeficiency Virus (HIV) 1 / 2 antibodies.  
 
The following screening tests should be undertaken locally up to 7 days prior to trial entry: 
• Physical examination including weight 
• Vital signs - temperature, pulse, respiratory rate and blood pressure (average of 3 BP 
readings) 
• ECOG performance status (see APPENDIX 1) 
• Adverse events - Adverse Events (AEs) and laboratory safety measurements will be 
graded per NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
v4.03 (see APPENDIX 2). All adverse events, whether gradable by CTCAE or not, will 
also be evaluated for seriousness 
• Concomitant medications – taken within four weeks prior to registration. 
• Full blood count (FBC) to include: white blood cells, haematocrit, haemoglobin, 
platelets, neutrophils, lymphocytes, red blood cells, monocytes, basophils, eosinophils, 
absolute neutrophil count 
• Urinalysis  
• Pregnancy test if applicable (serum β-HCG) 
• Comprehensive serum chemistry panel to include: sodium, potassium, urea, nitrogen, 
creatinine, magnesium, calcium (total), bilirubin (total), direct bilirubin, albumin, alkaline 
phosphatase (ALP), aspartate transferase (AST), alanine transferase (ALT), glucose, 
lactate dehydrogenase (LDH), phosphate, total protein, C reactive protein (CRP), 
Carcinoembryonic antigen (CEA) 
• Renal function - Patients must have adequate renal function as defined by Creatinine 
<1.5 x ULN concurrent with creatinine clearance >30 ml/min (calculated as per 
institutional standard)  
NOTE: An isotopic eGFR should be performed if the result of the calculated eGFR is borderline 
to prevent exclusion of patients with borderline eGFR values that are acceptable for trial entry. 
• Thyroid function and cortisol - analysis of cortisol, T3, T4 and Thyroid Stimulating 
Hormone (TSH) 
 
5.2.3 SCREENING LOG 
Investigators must keep a screening log of all patients who receive a Patient Information Sheet, 
all patients who consent to have tumour tissue sent for MS Status and Class II testing, and all 
patients that consent to the ANICCA-Class II trial. The following details of all patients screened 
for participation in this trial should be provided on the screening log: 
• TNO (if registered for screening) 
• Date screened 
• Date of Birth (Month and year only) 
• Sex 
• Whether the patient gave written informed consent 
• Whether the person was entered 
• Reasons(s) patient was not entered 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
TRIAL ENTRY 
 
6.1 
PATIENT REGISTRATION 
Once the investigator has confirmed the patient’s eligibility, the patient should be entered onto 
the trial using the eRDC system as described in section 5.2.1. 
During the trial entry process the patient’s TNO and confirmation of their eligibility will need to 
be provided. Following successful trial entry, a copy of the trial entry report should be printed 
and filed in the ISF and in the patient’s medical records. The TNO should be documented on 
the original signed Informed Consent Form filed in the ISF. A copy should also be sent to the 
ANICCA-Class II Trial Office for review. Additionally the eligibility form should be sent to the 
ANICCA-Class II Trial Office for review.  
Once a patient has been entered into the trial their name should be added to the Patient 
Identification Log. With the patient’s prior consent their General Practitioner (GP) should be 
informed that they are taking part in the trial. A GP Letter is provided for this purpose. Electronic 
and paper copies of the GP letter are available from the ANICCA-Class II Trial Office and 
should be printed or photocopied onto the headed paper of the local institution. A copy of the 
letter sent to the GP should be filed in the patient’s medical notes. 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
TREATMENT DETAILS 
 
7.1 
TRIAL TREATMENT 
7.1.1 DESCRIPTION OF INVESTIGATIONAL MEDICINAL PRODUCT (IMP) 
Nivolumab will be considered an IMP for the purposes of this trial. 
Full details of the IMP are contained in the ANICCA-Class II Pharmacy Manual, which also 
lists the Pharmacist’s’ responsibilities, details of labelling, record keeping for prescribing, 
dispensing, and accountability of the IMP. The ANICCA-Class II Pharmacy Manual will be sent 
to the responsible Pharmacist. 
 
7.1.2 INVESTIGATIONAL MEDICINAL PRODUCT SUPPLY AND LABELLING 
Nivolumab will be provided as vials containing 10 mg/mL concentrate of drug substance in 
solution for infusion.  
Nivolumab must be kept in a secure place under appropriate storage conditions (refer to 
pharmacy manual for full details).  
 
7.1.3 NIVOLUMAB ADMINISTRATION 
Nivolumab will be administered as a 60 minute IV infusion, with a window of -5 and +10 
minutes, at a flat dose of 480mg. A dosing interval every 4 weeks (Q4W) will be employed. 
See the ANICCA-Class II Pharmacy Manual for further information about nivolumab. 
 
Table 2 Dosing instructions for nivolumab 
Drug 
Dose/ 
Potency 
Dose 
Frequency 
Route of 
Administration 
Regimen/ 
Treatment Period 
Use 
Nivolumab 
480mg 
Q4W 
60 minute IV 
infusion 
Until progressive 
disease, 
unacceptable 
toxicity, withdrawal 
of consent to 
treatment or two 
years of treatment 
Experimental 
 
7.1.4 DRUG ACCOUNTABILITY 
The investigator must maintain adequate records documenting the use, loss, or other 
disposition, of the IMP for trial use. The ANICCA-Class II Trial Office will supply a drug 
accountability form which must be used for the IMP, or you may request to use your standard 
dispensing forms which should be approved prior to use by contacting the ANICCA-Class II 
ANICCA-Class II Trial Office. In either case, the forms must identify the IMP, including batch 
or code numbers and expiry dates, and account for its allocation on a patient-by-patient basis, 
including specific dates and quantities. The forms must be signed by the individual who 
dispenses the drug, and copies must be provided to the ANICCA-Class II Trial Office on 
request. The prescribed dose must also be recorded in the patient’s medical records. 
 
7.2 
TREATMENT SCHEDULE 
Patients should start nivolumab treatment within 7 days of registration. Patients will be 
administered nivolumab for a maximum of two years, or until disease progression, 
unacceptable toxicity or withdrawal of consent to treatment; each cycle being 28 days. Trial 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
treatment should be administered on day 1 of each cycle after all procedures/assessments 
have been completed as detailed in the schedule of events. Following the first cycle, trial 
treatment may be administered up to 3 days before or after the scheduled day 1 of each cycle 
due to administrative reasons. Trial treatment will be administered on an outpatient basis. At 
the first treatment visit the patient should be given a patient identification card and advised to 
carry it with them at all times while participating in the trial. 
 
At the end of the treatment period, the IMP manufacturer Bristol-Myers Squibb 
Pharmaceuticals Ltd. will not continue to supply nivolumab to patients unless the Sponsor-
Investigator chooses to extend their trial. The investigator is responsible in ensuring that the 
patient receives appropriate standard of care or other appropriate treatment in the independent 
medical judgement of the Investigator to treat the condition under study. 
 
7.3 
ASSESSMENTS 
 
7.3.1 ON-TREATMENT 
The following assessments should be performed on day 1 (or within 3 days prior) of 
each 28 day cycle: 
If below assessments were performed within 7 days of IMP administration they do not need 
repeating on day 1 of cycle 1. 
Day 1 of each 28 day cycle can be +/-3 days. 
• Vital signs - temperature, pulse, respiratory rate and blood pressure (average of 3 BP 
readings).  
• Physical Examination including weight 
• ECOG performance status (see APPENDIX 1) 
• Review AEs and Concomitant Medications - AEs and laboratory safety measurements 
will be graded per NCI Common Terminology Criteria for Adverse Events (CTCAE) 
version v4.03, (see APPENDIX 2). All AEs, whether gradable by CTCAE or not, will also 
be evaluated for seriousness 
• pregnancy test (urine or serum β-HCG) within 24 hours of IMP administration. 
• FBC to include: white blood cells, haematocrit, haemoglobin, platelets, neutrophils, 
lymphocytes, red blood cells, monocytes, basophils, eosinophils, absolute neutrophil 
count 
• Comprehensive serum chemistry panel to include: sodium, potassium, urea, nitrogen, 
creatinine, magnesium, calcium (total), bilirubin (total), direct bilirubin, albumin, ALP, 
AST or ALT, glucose, LDH, phosphate, total protein, CRP, CEA 
• Thyroid function and cortisol - analysis of cortisol, T3, T4 and TSH 
 
In addition to assessments undertaken every 28 days, as detailed above, the following 
assessments should also be performed: 
 
Every 9 weeks up to 45 weeks then every 12 weeks (within 3 days prior):  
• 
CT Tumour imaging with contrast (chest, abdomen, pelvis) - scans will be reported by 
RECIST 1.1 (APPENDIX 3). The same imaging technique has to be used in a patient 
throughout the trial. Tumour imaging will be performed every 9 weeks from treatment 
commencement (C1D1) up to 45 weeks followed by every 12 weeks until disease 
progression. Response status will be assessed by the trial site. 
• 
Patients may initially show evidence of disease progression as a response to 
immunotherapy therefore patients may be allowed to continue treatment beyond 
RECIST defined disease progression if they are clinically stable and tolerating therapy. 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Trial treatment must then be discontinued upon further progression defined as the 
presence of any new lesion or an additional 10% increase in existing tumour burden 
from time of the initial progression. 
 
7.3.2 TREATMENT DISCONTINUATION VISIT (END OF TREATMENT) 
The following assessments should be performed on the day the patient is discontinued from 
trial treatment: 
• Vital signs - temperature, pulse, respiratory rate and blood pressure (average of 3 BP 
readings) 
• Physical Examination including weight 
• ECOG performance status (see Appendix 1) 
• FBC to include: white blood cells, haematocrit, haemoglobin, platelets, neutrophils, 
lymphocytes, red blood cells, monocytes, basophils, eosinophils, absolute neutrophil 
count 
• Comprehensive serum chemistry panel to include: sodium, potassium, urea, nitrogen, 
creatinine, magnesium, calcium (total), bilirubin (total), direct bilirubin, albumin, ALP, 
AST or ALT, glucose, LDH, phosphate, total protein, CRP, CEA  
• Urinalysis 
• Coagulation parameters: Prothrombin (PT) / International Normalised Ratio (INR) and 
partial thromboplastin (aPTT) 
• Thyroid function and cortisol - analysis of cortisol, T3, T4 and TSH 
• Review Adverse Events and Concomitant Medications - Adverse Events (AEs) and 
laboratory safety measurements will be graded per NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version 4.03, (see APPENDIX 2). All adverse events, 
whether gradable by CTCAE or not, will also be evaluated for seriousness 
• Hyperprogression must be assessed where a patient has discontinued due to 
progressive disease. Hyperprogressive disease (HPD) in patients is defined as disease 
progression by RECIST criteria with a ≥2-fold increase in the tumour growth rate during 
the treatment period versus the reference period with this being the tumour growth before 
treatment.  
 
7.3.3 SAFETY FOLLOW UP VISIT  
The following assessments should be performed 28 days post discontinuation of trial 
treatment: 
PLEASE NOTE: For patients who begin another cancer therapy before 28 days after 
discontinuation of study therapy, the Safety Follow-Up Visit should occur prior to the patient 
receiving another cancer therapy. 
• Vital signs - temperature, pulse, respiratory rate and blood pressure (average of 3 BP 
readings) 
• Physical Examination including weight 
• ECOG performance status (see APPENDIX 1) 
• FBC to include: white blood cells, haematocrit, haemoglobin, platelets, neutrophils, 
lymphocytes, red blood cells, monocytes, basophils, eosinophils, absolute neutrophil 
count 
• Comprehensive serum chemistry panel to include: sodium, potassium, urea, nitrogen, 
creatinine, magnesium, calcium (total), bilirubin (total), direct bilirubin, albumin, ALP, 
AST or ALT, glucose, LDH, phosphate, total protein, CRP, CEA  
• Renal function - GFR 
• Thyroid function and cortisol - analysis of cortisol, T3, T4 and TSH 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
• Review Adverse Events and Concomitant Medications - Adverse Events (AEs) and 
laboratory safety measurements will be graded per NCI Common Terminology Criteria 
for Adverse Events (CTCAE) version v4.03, (see APPENDIX 2). All adverse events, 
whether gradable by CTCAE or not, will also be evaluated for seriousness 
 
7.3.4 FOLLOW UP 
The following assessments should be performed via telephone call (with the exception of CT 
scan): 
• Review Adverse Events every four weeks for up to 6 months post treatment 
discontinuation - Adverse Events (AEs) will be graded per NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.03, (see APPENDIX 2). All adverse 
events, whether gradable by CTCAE or not, will also be evaluated for seriousness. If at 
the 6 month review there are any toxicities at grade 2 or higher that the investigator 
considers to be related to the trial treatment then these should be followed up every 12 
weeks until they have reduced to grade 1 or less. 
• Further cancer treatment every four weeks up to 6 months and every 12 weeks 
thereafter. 
• CT Tumour imaging with contrast (chest, abdomen, pelvis) if patient has stopped trial 
treatment without progressive disease they should continue to be scanned according to 
schedule until progressive disease is identified. NOTE. In this situation, it is important if 
treatment is discontinued earlier than 45 weeks from commencement of treatment 
(C1D1), scans should continue to be performed every 9 weeks until this time point or 
disease progression. If disease progression has not been identified at 45 week scan then 
scans should continue to be performed every 12 weeks until disease progression or end 
of follow up. Scans will be reported by RECIST 1.1 (APPENDIX 3). Response status will 
be assessed by the trial site. Patients may initially show evidence of disease progression 
as a response to immunotherapy therefore patients may be allowed to continue 
treatment beyond RECIST defined disease progression if they are clinically stable and 
tolerating therapy. Trial treatment must then be discontinued upon further progression 
defined as the presence of any new lesion or an additional 10% increase in existing 
tumour burden from time of the initial progression. 
 
7.4 
SAMPLE COLLECTION 
7.4.1 BLOOD COLLECTION 
Blood collection for safety evaluation assumes priority over other procedures. Whenever 
possible, pre-treatment blood samples should be obtained by fresh peripheral venepuncture. 
If a patient does not have peripheral access, the sample may be collected from a central 
catheter immediately after an initial withdrawal of at least 10 ml of blood; or preferably, after a 
series of other blood sample collections from the central catheter. 
 
7.4.2 TRANSLATIONAL SAMPLES 
The following additional blood samples should be collected: 
 
Cytokine/Chemokine Panel and proteomics 
• Collected before start of first infusion followed by every alternate cycle from cycle 3 
onwards e.g. cycle 3, 5, 7 etc. (approx. every 8 weeks) and at Treatment 
Discontinuation Visit. 
Germline DNA 
• Collected before start of infusion at cycle 1. 
ctDNA 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
• Collected before start of first infusion followed by every alternate cycle from cycle 3 
onwards e.g. cycle 3, 5, 7 etc (approx. every 8 weeks) and at Treatment 
Discontinuation Visit. 
 
Processing and storage of blood samples are to be carried out as described in Laboratory 
Manual. 
 
7.5 
DOSE MODIFICATION AND TOXICITY MANAGEMENT 
AEs associated with nivolumab exposure may represent an immunologic etiology. Immune-
related AEs (irAEs) may occur shortly after the first dose or several months after the last dose 
of nivolumab treatment and may affect more than one body system simultaneously. Based on 
existing clinical trial data, most irAEs were reversible and could be managed with interruptions 
of nivolumab, administration of corticosteroids and/or other supportive care. For suspected 
irAEs, ensure adequate evaluation to confirm etiology or exclude other causes. Based on the 
severity of irAEs, withhold or permanently discontinue nivolumab and administer 
corticosteroids. Dose modification and toxicity management guidelines for irAEs associated 
with nivolumab are provided in Table 3. For any general disorders, if the performance status 
is poor, the investigator should withhold or discontinue treatment. 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Table 3 Dose modification and toxicity management guidelines for immune-related AEs associated with nivolumab  
Immune-related 
AEs 
Toxicity grade or 
conditions 
Action taken to 
nivolumab2, 3 
AE management with 
corticosteroid1, 4 and/or other 
therapies 
Monitoring and Supportive Care 
Pneumonitis  
Grade 2 
Withhold  
• Administer corticosteroids (initial 
dose of 1-2mg/kg prednisone or 
equivalent) followed by taper 
• 
Monitor subjects for signs and 
symptoms of pneumonitis 
• 
Evaluate subjects with suspected 
pneumonitis with radiographic imaging 
and initiate corticosteroid treatment 
• 
Add prophylactic antibiotics for 
opportunistic infections 
Grade 3 or 4 
Permanently discontinue 
Diarrhoea / colitis  Grade 2 or 3 
Withhold 
• Administer corticosteroids (initial 
dose of 1-2mg/kg prednisone or 
equivalent). 
• Nivolumab can be recommenced 
upon improvement of symptoms 
and after corticosteroid taper 
• For persistent diarrhoea/colitis, 
nivolumab should only be 
resumed if there is improvement 
with steroids; otherwise, it would 
be permanently discontinued 
• If diagnosis of corticosteroid 
refractory immune-related colitis 
is confirmed addition of an 
alternative immunosuppressive 
agent to the corticosteroid 
therapy, or replacement of the 
corticosteroid therapy, should be 
considered. 
 
 
• 
Monitor subjects for signs and 
symptoms of enterocolitis (i.e. 
diarrhoea, abdominal pain, blood or 
mucus in stool with or without fever) 
and of bowel perforation (i.e. peritoneal 
signs and ileus). 
• 
Subjects with ≥ Grade 2 diarrhoea 
suspecting colitis should consider GI 
consultation and performing endoscopy 
and cross sectional imaging to rule out 
colitis. Investigations should also be 
performed to exclude infective causes. 
• 
Subjects with diarrhoea/colitis should 
be advised to drink liberal quantities of 
clear fluids. If sufficient oral fluid intake 
is not feasible, fluid and electrolytes 
should be substituted via IV infusion. 
• 
Cytomegalovirus (CMV) 
infection/reactivation has been reported 
in patients with corticosteroid-refractory 
immune-related colitis. Infectious and 
other aetiologies of diarrhoea should be 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
Action taken to 
nivolumab2, 3 
AE management with 
corticosteroid1, 4 and/or other 
therapies 
Monitoring and Supportive Care 
Grade 4 
Permanently discontinue 
• Administer corticosteroids (initial 
dose of 1-2mg/kg prednisone or 
equivalent). 
 
• If diagnosis of corticosteroid 
refractory immune-related colitis 
is confirmed addition of an 
alternative immunosuppressive 
agent to the corticosteroid 
therapy, or replacement of the 
corticosteroid therapy, should be 
considered. 
 
ruled out,therefore appropriate 
laboratory tests and additional 
examinations must be performed. If 
diagnosis of corticosteroid refractory 
immune-related colitis is confirmed 
addition of an alternative 
immunosuppressive agent to the 
corticosteroid therapy, or replacement 
of the corticosteroid therapy, should be 
considered. 
AST 
/ 
ALT 
elevation 
or 
Increased 
Total 
Bilirubin 
Grade 2 
Withhold 
• Administer corticosteroids (initial 
dose of 0.5- 1mg/kg prednisone 
or equivalent). 
• 
Monitor with liver function tests 
(consider weekly or more frequently, 
withhold until liver enzyme value 
returned to baseline or is stable). 
Grade 3 or 4  
Permanently discontinue 
• Administer corticosteroids (initial 
dose of 1-2mg/kg prednisone or 
equivalent. 
Diabetes 
Grade 3 
Withhold 
• For symptomatic diabetes initiate 
insulin replacement therapy as 
appropriate. 
• 
Monitor subjects blood sugar levels. 
Grade 4 
Permanently discontinue 
Hypophysitis 
Symptomatic Grade 2 or 3 
Withhold 
• Administer corticosteroids and 
initiate hormonal replacements 
as clinically indicated. 
• 
Monitor for signs and symptoms of 
hypophysitis (including hypopituitarism). 
Grade 4  
Permanently discontinue  

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
Action taken to 
nivolumab2, 3 
AE management with 
corticosteroid1, 4 and/or other 
therapies 
Monitoring and Supportive Care 
Hyperthyroidism  
Symptomatic Grade 2 or 3 
Withhold 
• Treat with non-selective beta-
blockers (e.g. propranolol) or 
thioamides) as appropriate. 
• For symptomatic 
hyperthyroidism initiate 
antithyroid therapy as 
appropriate. 
• 
Monitor for signs and symptoms of 
thyroid disorders. 
Grade 4  
Permanently discontinue 
Hypothyroidism 
Symptomatic Grade 2 or 3 
Withhold 
• 
Initiate thyroid replacement 
hormones (e.g. levothyroxine or 
liothyronine) per standard of 
care. 
• 
Monitor for signs and symptoms of 
thyroid disorders. 
Grade 4  
Permanently discontinue 
Adrenal 
insufficiency  
Grade 2 
Withhold 
• Administer corticosteroids and 
initiate hormonal replacements 
as clinically indicated. 
• 
Monitor for signs and symptoms of 
adrenal insufficiency. 
Grade 3 or 4 
Permanently discontinue 
Creatinine 
elevation 
Grade 2 or 3 
Withhold  
• Administer corticosteroids 
(prednisone 1-2mg/kg or 
equivalent). 
• 
Monitor changes of renal function, 
withhold until creatinine returns to 
baseline or is stable. 
 
Grade 4  
Permanently discontinue 
Rash 
Grade 3 
Withhold 
• 
If severe administer 
corticosteroids (1-2 mg/kg/day) 
methylprednisolone or 
equivalent. 
• 
Monitor for rash and other 
signs/symptoms of skin disorders. 
Grade 4 
Permanently discontinue 
Stevens-Johnson 
Syndrome (SJS) 
or 
Toxic 
Epidermal 
Necrolysis  
- 
Permanently discontinue 
 
 
Myocarditis 
Grade 2 
Withhold dose 
• 
Based on severity administer 
corticosteroids (prednisone 1-
2mg/kg or equivalent). 
 
Grade 3/4 
Permanently discontinue 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Immune-related 
AEs 
Toxicity grade or 
conditions 
Action taken to 
nivolumab2, 3 
AE management with 
corticosteroid1, 4 and/or other 
therapies 
Monitoring and Supportive Care 
All Other immune-
related AEs 
Grade 3 (first occurrence) 
Withhold 
• Based on severity of AE 
administer corticosteroids  
• 
Ensure adequate evaluation to confirm 
etiology or exclude other causes 
Grade 4 or recurrent Grade 3; 
persistent Grade 2 or 3 
despite treatment 
modification ; inability to 
reduce corticosteroid dose to 
10 mg prednisone or 
equivalent per day 
Permanently discontinue 
Footnotes: General Instructions for management of irAE 
1. Corticosteroid taper should be initiated upon AE improving to Grade 1 or less and continue to taper over at least 4 weeks. 
2. For situations where nivolumab has been withheld, nivolumab can be resumed after AE has been reduced to Grade 1 or 0 and corticosteroid has been tapered.. For subjects with Grade 3 or 4 
immune-related endocrinopathy, nivolumab may be resumed when AE improves to Grade 2 or lower and is controlled with hormonal replacement therapy. 
3. For situation where nivolumab is withheld initially, nivolumab should be permanently discontinued if AE does not resolve within 12 weeks of last dose or corticosteroids cannot be reduced to ≤ 10 
mg prednisone or equivalent per day within 12 weeks.  
4. For severe and life-threatening irAEs, IV corticosteroid should be initiated first followed by oral steroid. Other immunosuppressive treatment should be initiated if irAEs cannot be controlled by 
corticosteroids. 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Nivolumab may be interrupted for situations other than treatment-related AEs such as 
medical/surgical events or logistical reasons not related to trial therapy (e.g. elective surgery, 
unrelated medical events, patient vacation, and/or holidays). Subjects should recommence 
trial therapy within 3 weeks of the scheduled interruption, unless otherwise discussed with the 
ANICCA-Class II Trial Office. The reason for interruption should be documented in the patient's 
medical notes and on the Case Report Form (CRF). 
 
7.6 
TREATMENT COMPLIANCE 
All dose modifications, delays and omissions must be recorded on the CRF. 
 
7.7 
CONCOMITANT MEDICATION 
7.7.1 ACCEPTABLE CONCOMITANT MEDICATIONS 
Throughout the trial any concomitant medication or therapy deemed necessary to provide 
adequate supportive care may be prescribed and should be recorded within the CRF including 
all prescription, over-the-counter (OTC) and IV medications and fluids, with the exception of 
those detailed in section 7.7.2. The indication for the treatment should be recorded at the same 
time.  
If changes occur during the trial period e.g. drug dosage, frequency, route date, this should 
also be documented in the CRF. 
All concomitant medications received within 28 days prior to trial registration, during trial 
treatment and 28 days after the last dose of trial treatment should be recorded. Concomitant 
medications administered after 28 days of the last dose of trial treatment only need to be 
recorded when reporting Serious Adverse Events (SAEs). 
Antibiotics are allowed to be given to be treated for infections however these may decrease 
the efficacy of Nivolumab. Antibiotics should only be given if essential and ideally should not 
be given 28 days before treatment and 2 months after treatment has stopped. 
7.7.2 PROHIBITED CONCOMITANT MEDICATIONS 
Subjects are prohibited from receiving the following therapies during the Screening and 
Treatment Phase of this trial: 
• Anti-cancer systemic chemotherapy or biological therapy within 28 days prior to the first 
dose of trial treatment and while participating in the trial. 
• Immunotherapy not specified in this protocol. 
• Chemotherapy not specified in this protocol. 
• Investigational agents other than nivolumab. 
• Radiation therapy  
o Note: Palliative Radiation therapy may be allowed after consultation with the 
ANICCA-Class II Trial Office. 
• Live vaccines within 30 days prior to the first dose of trial treatment and while participating 
in the trial and for 3 months after the last dose of therapy. Examples of live vaccines 
include, but are not limited to, the following: measles, mumps, rubella, chicken pox, 
yellow fever, rabies, BCG, and typhoid (oral) vaccine. Seasonal influenza vaccines for 
injection are generally killed virus vaccines and are allowed; however intranasal 
influenza vaccines (e.g. Flu-Mist®) are live attenuated vaccines, and are not allowed. 
COVID19 viral vector RNA vaccines are permitted but should be recorded on the 
Concommittant Medication form. 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
• Glucocorticoids for any purpose other than to manage symptoms of an immune-related 
adverse event. The use of physiologic doses of corticosteroids may be approved after 
consultation with the ANICCA-Class II Trial Office. 
• Whilst participating on the trial, patients may be given systemic steroids due to an acute 
medical situation but the steroids may only be given for a maximum of 2 weeks. During 
this period, trial treatment must stop and can be restarted when the steroid administration 
is complete. If the subject requires the continued use of steroid treatment for more than 
2 weeks, they should be withdrawn from the trial. 
• Any form of immunosuppressive therapy within 7 days prior to the first dose of trial 
treatment and while participating on the trial. Replacement therapy (e.g. thyroxine, 
insulin, or physiologic corticosteroid replacement therapy for adrenal or pituitary 
insufficiency, etc.) is not considered a form of systemic treatment. 
• Any botanical preparation (e.g. herbal supplements or traditional Chinese medicines) 
intended to treat the disease under study or provide supportive care. 
 
Subjects who, on the assessment by the Investigator, require the use of any of the 
aforementioned treatments for clinical management should be discontinued from trial 
treatment. Subjects may receive other medications that the Investigator deems to be medically 
necessary. 
There are no prohibited therapies during the post-treatment follow-up phase. 
 
7.8 
CONTRACEPTION 
7.8.1 WOMEN OF CHILDBEARING POTENTIAL 
Women of childbearing potential are defined as women who have not had a hysterectomy and 
oophorectomy. Women with amenorrhea for <2 years will only be considered not to be of 
reproductive potential if they have prior documentation in the medical notes confirming post-
menopausal status. 
Adequate contraception should be used from the time of screening, during the trial and for at 
least 23 weeks after completion of treatment.  
Acceptable methods of contraception include total abstinence (if this is the patient’s usual and 
preferred lifestyle choice), tubal ligation, combined oral, transdermal or intra-vaginal hormonal 
contraceptives, medroxyprogesterone injections (e.g. Depo-provera), copper-banded intra-
uterine devices, hormone impregnated intra-uterine systems and vasectomised partners. All 
methods of contraception (with the exception of total abstinence) should be used in 
combination with the use of a condom by their male sexual partner for intercourse. 
7.8.2 MALES 
Male patients with sexual partners who are pregnant or who could become pregnant (i.e. 
women of child-bearing potential) should use a condom during sexual intercourse during the 
trial and for at least 7 months after completion of treatment. Partners of male patients should 
also use effective contraception that is not a female condom. 
Male patients are prohibited from giving sperm donation during the trial and for at least 7 
months after completing treatment. 
 
7.9 
PROGRESSION AND DEATH 
The ANICCA-Class II Trial Office should be notified immediately if a patient progresses or dies 
by completion of the progression form or the death form (see section 10.1).  

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
7.10 TRIAL TREATMENT DISCONTINUATION AND WITHDRAWAL OF CONSENT 
7.10.1 DISCONTINUATION OF INVESTIGATIONAL MEDICINAL PRODUCT 
Patients should discontinue trial treatment in the following circumstances: 
• Intolerable toxicity 
• Confirmed disease progression - Hyperprogression must be assessed where a patient 
has discontinued due to progressive disease, see section 7.3.2 for definition. 
• Pregnancy 
• Severe non-compliance to protocol 
• Investigator decision, for example if the patient requires a prohibited concomitant 
medication 
• Completion of two years treatment 
The ANICCA-Class II Trial Office should be notified of treatment discontinuation immediately 
via completion a Treatment Discontinuation Form.  
 
7.10.2 WITHDRAWAL OF CONSENT 
Patients may withdraw consent at any time without reason. For the purposes of this trial three 
types of withdrawal are defined: 
• The patient would like to withdraw from trial treatment, but is willing to be followed up in 
accordance with the schedule of assessments (i.e. the patient has agreed that data can 
be collected and used in the trial analysis) 
• The patient would like to withdraw from trial treatment and does not wish to attend trial 
visits in accordance with the schedule of assessments but is willing to be followed up at 
standard clinic visits (i.e. the patient has agreed that data can be collected at standard 
clinic visits and used in the trial analysis) 
• The patient would like to withdraw from trial treatment and is not willing to be followed 
up for the purposes of the trial at any further visits (i.e. only data collected prior to the 
withdrawal of consent can be used in the trial analysis) 
A patient that decides to withdraw from nivolumab treatment should always be asked about 
the presence of any AEs. 
The details of withdrawal (date, reason (if patient willing to provide) and type of withdrawal) 
should be clearly documented in the source data. A Withdrawal Form should be completed to 
notify the ANICCA-Class II Trial Office of the patient’s withdrawal from the trial. 
 
 
 
 
COVID 19 PANDEMIC 
 
The ANICCA Class II trial remains open during the Covid-19 pandemic, although individual 
trusts may make the decision to close. The Covid-19 pandemic may have a significant impact 
on patient recruitment, trial visits and treatment, including standard of care (SOC). Patient 
safety is paramount and Investigators are advised to follow local practices and document any 
deviations from the protocol on a deviation form. During these exceptional circumstances, 
reasonable deviations would not trigger additional monitoring visits. Due to Covid-19 
associated clinic visit restrictions, sites are permitted to conduct telephone and virtual 
consultations instead of face-to-face consultations. Blood tests may be performed locally at 
GP surgeries or community based clinics, if patients are unable to have these required safety 
assessments at their hospitals. We appreciate that it may not always be possible to obtain 
these results for the CRF within the normal expected timeframe.  

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Scans that are missed due to Covid-19 restrictions and reduced scanning capacity should be 
recorded on a deviation form. Future scheduled scans, as with all trial procedures should 
continue per protocol as soon as possible. 
 
 
TRANSLATIONAL RESEARCH 
 
Exploratory outcomes will be based on the identification of possible biomarkers predictive of 
response to nivolumab. Previous studies looking at Neoadjuvant immune-checkpoint blockade 
in resectable colon cancer identified  that the levels of PD-1 and CD-8+ were predictive of 
patient response to checkpoint blockade therapy such as nivolumab25. During class II 
expression 
screening, 
if 
class 
II 
expression 
(>1%) 
is 
observed 
subsequent 
immunohistochemistry staining for CD-8+ and PD-1 will be carried out to look for 
supplementary biomarkers of response to nivolumab. This will be performed by the Molecular 
Pathology Diagnostic Service at the Queen Elizabeth Hospital Birmingham.  Secondly we will 
analyse blood samples to identify possible biomarkers of response. This will be a purely 
discovery analysis and new putative biomarkers would require prospective validation. Sample 
analysis will be performed at the University of Birmingham or affiliated academic institutions 
either during or upon completion of the trial. 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 ADVERSE EVENT REPORTING 
The collection and reporting of AEs will be in accordance with the Medicines for Human Use 
Clinical Trials Regulations 2004 and its subsequent amendments. Definitions of different types 
of AE are listed in APPENDIX 4. The Investigator should assess the seriousness and causality 
(relatedness) of all AEs experienced by the patient (this should be documented in the source 
data) with reference to the summary of product characteristics (SPC). 
 
10.1 REPORTING REQUIREMENTS 
10.1.1 ADVERSE EVENTS 
All medical occurrences which meet the definition of an AE (see APPENDIX 4 for definition) 
should be reported. 
 
10.1.2 LABORATORY TEST ABNORMALITIES 
All laboratory test results captured as part of the trial should be recorded following institutional 
procedures. Test results that constitute SAEs (see APPENDIX 4 for definition) should be 
documented and reported to the ANICCA-Class II Trial Office as such. 
The following laboratory abnormalities should be documented and reported appropriately: 
• any laboratory test result that is clinically significant or meets the definition of an SAE 
• any laboratory abnormality that required the participant to have study drug discontinued 
or interrupted 
• any laboratory abnormality that required the subject to receive specific corrective 
therapy 
It is expected that wherever possible, the clinical rather than laboratory term would be used 
by the reporting investigator (e.g., anemia versus low hemoglobin value). 
 
10.1.3 DRUG INDUCED LIVER INJURY (DILI) EVENTS  
DILI events will be reported and captured as part of the safety reporting profile and those 
meeting the criteria below will require expedited reporting to the ANICCA-Class II Trial Office 
as SAEs. 
Wherever possible, timely confirmation of initial liver-related laboratory abnormalities should 
occur prior to the reporting of a potential DILI event. Potential drug induced liver injury is 
defined as: 
 
1. AT (ALT or AST) elevation > 3 times upper limit of normal (ULN) 
2. Total bilirubin > 2 times ULN, without initial findings of cholestasis (elevated serum 
alkaline phosphatase) 
3. No other immediately apparent possible causes of AT elevation and hyperbilirubinemia, 
including, but not limited to, viral hepatitis, pre-existing chronic or acute liver disease, or 
the administration of other drug(s) known to be hepatotoxic. 
 
10.1.4 SERIOUS ADVERSE EVENTS 
Investigators should report AEs that meet the definition of an SAE (see APPENDIX 4 for 
definition) as described in section  
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
10.1.5 MONITORING PREGNANCIES FOR POTENTIAL SERIOUS ADVERSE 
EVENTS 
It is important to monitor the outcome of pregnancies of patients and/or their partners in order 
to provide SAE data on congenital anomalies or birth defects. 
In the event that a patient or their partner becomes pregnant during the SAE reporting period, 
please complete a Pregnancy Notification Form (providing the patient’s details) and return to 
the ANICCA-Class II Trial Office as soon as possible and ideally no later than 24 hours from 
first becoming aware. The patient should be given a release of medical information form or the 
patient should be asked to give this to their partner. If the patient/partner is happy to provide 
information on the outcome of their pregnancy they should sign the release of medical 
information form. Once consent has been obtained provide details of the outcome of the 
pregnancy on a follow-up Pregnancy Notification Form and if necessary also complete an SAE 
Form. Follow-up information will be collected for up to 10 years. 
 
10.1.6 REPORTING PERIOD 
Details of all AEs will be documented and reported from the date patient consented to main 
trial until 6 months after treatment discontinuation. If at the 6 month review there are any 
toxicities at grade 2 or higher that the investigator considers to be related to the trial treatment 
then these should be followed up until they have reduced to grade 1 or less. 
SAEs that are judged to be at least possibly related to IMP must still be reported in an expedited 
manner irrespective of how long after IMP administration the reaction occurred. 
 
10.2 REPORTING PROCEDURE 
10.2.1 REPORTING PROCEDURES FOR SITE 
10.2.1.1 ADVERSE EVENTS 
AEs should be reported on an AE Monitoring Form (and where applicable on an SAE Form). 
An AE Monitoring Form should be completed at each visit. 
AEs will be reviewed using the CTCAE, version v4.03 (see APPENDIX 2). For each AE, the 
highest grade observed since the last visit should be recorded. 
 
10.2.1.2 SERIOUS ADVERSE EVENTS 
For more detailed instructions on SAE reporting refer to the SAE Form Completion Guidelines 
contained in the ISF. 
AEs defined as serious and which require reporting as an SAE should be reported on an SAE 
Form. When completing the form, the Investigator will be asked to define the causality and the 
severity of the AE, which should be documented using the CTCAE version 4.03. 
On becoming aware that a patient has experienced an SAE, the Investigator (or their delegate) 
must complete, date and sign an SAE Form. The form should be emailed to the ANICCA-Class 
II Trial Office using one of the numbers listed below as soon as possible and no later than 24 
hours after first becoming aware of the event: 
To report an SAE, email the SAE Formto: 
reg@trials.bham.ac.uk 
On receipt the ANICCA-Class II Trial Office will allocate each SAE a unique reference number. 
This number will be emailed back to the site as proof of receipt. If confirmation of receipt is not 
received within 1 working day please contact the ANICCA-Class II Trial Office. The SAE 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
reference number should be quoted on all correspondence and follow-up reports regarding the 
SAE. 
For SAE Forms completed by someone other than the Investigator, the Investigator will be 
required to countersign the original SAE Form to confirm agreement with the causality and 
severity assessments. The form should then be returned to the Trials Office in the post and a 
copy kept in the ISF. Investigators should also report SAEs to their own Trust in accordance 
with local practice. 
 
10.2.1.3 PROVISION OF FOLLOW-UP INFORMATION 
Patients should be followed up until resolution or stabilisation of the event. Follow-up 
information should be provided on a new SAE Form (refer to the SAE Form Completion 
Guidelines for further information). 
 
10.2.2 ANICCA-CLASS II TRIAL OFFICE 
On receipt of an SAE Form, seriousness and causality will be determined independently by a 
Clinical Coordinator. An SAE judged by the Investigator or Clinical Coordinator to have a 
reasonable causal relationship with the trial medication will be regarded as a Serious Adverse 
Reaction (SAR). The Clinical Coordinator will also assess all SARs for expectedness. If the 
event meets the definition of a SAR that is unexpected (i.e. is not defined in the Reference 
Safety Information) it will be classified as a Suspected Unexpected Serious Adverse Reaction 
(SUSAR). 
 
10.2.3 REPORTING TO THE COMPETENT AUTHORITY AND RESEARCH ETHICS 
COMMITTEE 
9.2.3.1 
SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS 
The ANICCA-Class II Trial Office will report a minimal data set of all individual events 
categorised as a fatal or life threatening SUSAR to the Medicines and Healthcare products 
Regulatory Agency (MHRA) and Research Ethics Committee (REC) within 7 days. Detailed 
follow-up information will be provided within an additional 8 days. 
All other events categorised as SUSARs will be reported within 15 days. 
 
9.2.3.2 
SERIOUS ADVERSE REACTIONS 
The ANICCA-Class II Trial Office will report details of all SARs (including SUSARs) to the 
MHRA and REC annually from the date of the Clinical Trial Authorisation, in the form of a 
Development Safety Update Report. 
 
9.2.3.3 
ADVERSE EVENTS 
Details of all AEs will be reported to the MHRA on request.  
 
10.2.3.1 OTHER SAFETY ISSUES IDENTIFIED DURING THE COURSE OF THE TRIAL 
The MHRA and REC will be notified immediately if a significant safety issue is identified during 
the course of the trial. 
 
10.2.4 INVESTIGATORS 
Details of all SUSARs and any other safety issue which arises during the course of the trial will 
be reported to Principal Investigators. A copy of any such correspondence should be filed in 
the ISF. 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
10.2.5 TRIAL STEERING COMMITTEE 
The Trial Steering Committee will review all SAEs. 
 
10.2.6 MANUFACTURER OF INVESTIGATIONAL MEDICINAL PRODUCT 
All SAEs will be reported to Bristol-Myers Squibb Pharmaceuticals Ltd. (IMP manufacturer) 
within an agreed timeframe from first awareness of the event at the ANICCA-II Trial Office. 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 DATA HANDLING AND RECORD KEEPING 
 
11.1 DATA COLLECTION 
The Case Report Form (CRF) will comprise the forms detailed below in Table 4. 
 
Table 4 Case Report Form 
Form 
Summary of data recorded 
Schedule 
for 
submission 
Screening Biopsy 
Form 
Patient details, details of patient’s CRC 
(with copy of diagnostic biopsy report) and 
biopsy sample provided for MS status and 
Class II expression testing.  
Must 
be 
sent 
with 
biopsy sample 
Eligibility 
Checklist 
Confirmation of patient eligibility. 
Email 
at 
point 
of 
registration Original to 
be posted within one 
week of registration. 
Screening 
Registration Form 
Patient details 
Within one week of 
registration 
Medical History 
Form 
Patient’s 
medical 
history 
including 
smoking and alcohol status and relevant 
significant 
medical 
and 
autoimmune 
conditions 
Within one week of 
registration 
Previous Cancer 
Treatment Form 
Any treatment patient has previously 
received for their CRC, best response for 
each treatment and reasons for stopping 
each treatment 
Within one week of 
registration 
Adverse Event 
Monitoring Form 
Any adverse events patient suffers during 
screening, treatment and follow up 
Baseline AE form – 
within 
one 
week 
of 
registration, Treatment 
AE form – within one 
week of treatment visit, 
Follow up AE form – 
within one week of visit 
Concomitant 
Medication Log 
Any concomitant medication patient is 
taking during screening, baseline and 
follow up 
Baseline 
concomitant 
medication log – within 
one 
week 
of 
registration, Treatment 
concomitant medication 
log – within one week of 
treatment visit, Follow 
up 
concomitant 
medication log – within 
one week of visit 
Treatment Form 
Pre-treatment assessment data, details of 
nivolumab delivery including date given, 
Within one week of 
treatment visit 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
dose 
administered, 
details 
of 
dose 
reduction/delay/interruption if necessary. 
Details of translational blood sample 
collection. 
Laboratory Tests 
Form 
Details 
of 
clinical 
chemistry 
and 
haematological assessments.  
Within one week of 
registration and then 
within 
one 
week 
of 
treatment visit. 
Response 
Evaluation Form-
Baseline 
Details of target/non-target lesions at 
baseline. 
Within one week of 
registration 
Response 
Evaluation Form 
Target/non-target 
tumour 
assessment 
during treatment and follow up according 
to RECIST 1.1.  
Treatment 
response 
evaluation form – within 
one 
week 
of 
assessment, Follow up 
response 
evaluation 
form – within one week 
of assessment. 
Treatment 
Discontinuation 
Form 
Date treatment was discontinued and 
reason for discontinuation 
Immediately 
upon 
discontinuation 
of 
treatment 
Trial Entry Form 
Confirmation of entry into the main trial 
Within one week of 
entry into main trial 
End of Treatment 
Form 
End of treatment assessment data, details 
of translational blood sample collection. 
Within one week of end 
of treatment visit 
Safety Follow up 
Visit Form 
Assessments performed at 28 day post 
discontinuation safety visit 
Within one week of visit 
Follow up Form 
Date contact was last made with patient 
and any further treatment they have 
received for their CRC 
Within one week of 
contact 
Death Form 
Date and cause of death 
Immediately 
upon 
notification of patient’s 
death 
Deviation Form 
Completed in the event of a deviation from 
the protocol 
Immediately 
upon 
discovering deviation 
Withdrawal Form 
Used to notify the Trials Office of patient 
withdrawal from the trial 
Immediately 
upon 
patient withdrawal 
Pregnancy 
Notification Form 
Dates related to pregnancy and outcome 
Within 
24 
hours 
of 
becoming 
aware 
of 
pregnancy and outcome 
Serious Adverse 
Event Form 
Completed in the event of patient 
experiencing a serious adverse event 
(refer to APPENDIX 4 for definition)  
Within 
24 
hours 
of 
awareness of event 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
This trial will use an electronic remote data capture (eRDC) system which will be used for 
completion of the CRF. Access to the eRDC system will be granted to individuals via the 
ANICCA-Class II Trial Office. The eligibility checklist, SAE reporting and Notification of 
Pregnancy will be paper-based. 
The CRF must be completed by the Investigator or an authorised member of the site research 
team (as delegated on the Site Signature and Delegation Log) within the timeframe listed 
above. The exceptions to this are the SAE Form and Eligibility Checklist, which must be co-
signed by the Investigator. SAE Forms should be emailed to the ANICCA-Class II Trial Office 
as soon as possible and no later than 24 hours after first becoming aware of the event.  
Entries on the paper based forms should be made in ballpoint pen, in blue or black ink, and 
must be legible. Any errors should be crossed out with a single stroke, the correction inserted 
and the change initialled and dated. If it is not obvious why a change has been made, an 
explanation should be written next to the change.  
 
Data reported on each form should be consistent with the source data or the discrepancies 
should be explained. If information is not known, this must be clearly indicated on the form. All 
missing and ambiguous data will be queried. All sections are to be completed before returning. 
In all cases it remains the responsibility of the Investigator to ensure that the CRF has been 
completed correctly and that the data are accurate. 
The format and content in the CRF may be amended by the ANICCA-Class II Trial Office, as 
appropriate, throughout the duration of the trial. Whilst this will not constitute a protocol 
amendment, sites will be notified of new versions of the form when they are available in the 
eRDC system, and new versions of the form must be implemented by participating sites 
immediately on receipt. 
 
11.2 ARCHIVING 
It is the responsibility of the Principal Investigator to ensure all essential trial documentation 
and source records (e.g. signed Informed Consent Forms, ISF, Pharmacy File, patients’ 
hospital notes, copies of CRFs etc.) at their site are securely retained for at least 25 years after 
the end of the trial. Do not destroy any documents without prior approval from the CRCTU 
Archivist.  
 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 QUALITY MANAGEMENT 
 
12.1 SITE SET-UP AND INITIATION 
All sites will be required to sign a Clinical Trial Site Agreement prior to participation. In addition 
all participating Investigators will be asked to sign the necessary agreements and registration 
forms; and supply a current CV to the ANICCA-Class II Trial Office. All members of the site 
research team will also be required to sign the Site Signature and Delegation Log, which should 
be returned to the ANICCA-Class II Trial Office. Prior to commencing recruitment all sites will 
undergo a process of initiation. Key members of the site research team will be required to 
attend either a meeting or a teleconference covering aspects of the trial design, protocol 
procedures, AE reporting, collection and reporting of data and record keeping. Sites will be 
provided with an Investigator Site File and a Pharmacy File containing essential 
documentation, instructions, and other documentation required for the conduct of the trial. The 
ANICCA-II Trial Office must be informed immediately of any change in the site research team. 
 
12.2 ON-SITE MONITORING 
Monitoring will be carried out as required following a risk assessment and as documented in 
the ANICCA-Class II Trial Quality Management Plan. Additional on-site monitoring visits may 
be triggered; for example by poor CRF return, poor data quality, low SAE reporting rates, an 
excessive number of patient withdrawals or deviations. If a monitoring visit is required, the 
ANICCA-Class II Trial Office will contact the site to arrange a date for the proposed visit and 
will provide the site with written confirmation. Investigators will allow the ANICCA-Class II trial 
staff access to source documents as requested. 
 
12.3 CENTRAL MONITORING 
Where a patient has given explicit consent sites are requested to send in copies of signed 
Informed Consent Forms for in-house review. 
Trials staff will be in regular contact with the site research team to check on progress and 
address any queries that they may have. Trials staff will check incoming Case Report Forms 
for compliance with the protocol, data consistency, missing data and timing. Sites will be sent 
Data Clarification Forms requesting missing data or clarification of inconsistencies or 
discrepancies. For CRF on eRDC, data clarifications will be raised on this system. Sites are 
expected to answer the data clarifications in a timely manner. 
Sites may be suspended from further recruitment in the event of serious and persistent non-
compliance with the protocol and/or GCP, and/or poor recruitment. Any major problems 
identified during monitoring may be reported to the ANICCA-Class II TMG or TSC, and the 
relevant regulatory bodies. This includes reporting serious breaches of GCP and/or the trial 
protocol to the REC and the MHRA. 
 
12.4 AUDIT AND INSPECTION 
The Investigator will permit trial-related monitoring, audits, ethical review, and regulatory 
inspection(s) at their site, providing direct access to source data/documents. 
Sites are also requested to notify the ANICCA-Class II Trial Office of any MHRA inspections. 
 
12.5 NOTIFICATION OF SERIOUS BREACHES 
In accordance with Regulation 29A of the Medicines for Human Use (Clinical Trials) 
Regulations 2004 and its amendments the Sponsor of the trial is responsible for notifying the 
licensing authority in writing of any serious breach of: 
• The conditions and principles of GCP in connection with that trial or; 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
• The protocol relating to that trial, within 7 days of becoming aware of that breach 
For the purposes of this regulation, a “serious breach” is a breach which is likely to effect to a 
significant degree: 
• The safety or physical or mental integrity of the subjects of the trial; or 
• The scientific value of the trial 
Sites are therefore requested to notify the ANICCA-Class II Trial Office of a suspected trial-
related serious breach of GCP and/or the trial protocol. Where the ANICCA-Class II Trial Office 
is investigating whether or not a serious breach has occurred sites are also requested to 
cooperate with the ANICCA-Class II Trial Office in providing sufficient information to report the 
breach to the MHRA where required and in undertaking any corrective and/or preventive 
action. 
 
 
 END OF TRIAL DEFINITION 
 
The end of trial will be six months after the last data capture. This will allow sufficient time for 
the completion of protocol procedures, data collection and data input. The ANICCA-Class II 
Trial Office will notify the MHRA and REC that the trial has ended and will provide them with a 
summary of the clinical trial report within 12 months of the end of trial. 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 STATISTICAL CONSIDERATIONS 
 
14.1 DEFINITION OF OUTCOME MEASURES 
14.1.1 PRIMARY OUTCOME MEASURE 
Durable clinical benefit (DCB) 
A patient will be defined as experiencing DCB if they remain free of disease progression at 
their third trial specific CT scan or MRI scan since treatment start date (i.e. at approximately 
27 weeks) or at any CT/MRI scan after 27 weeks that shows the patient remains free of disease 
progression. While either CT or MRI may be used, as per RECIST 1.1, CT is the preferred 
imaging technique in this trial. 
 
14.1.2 SECONDARY OUTCOME MEASURES 
14.1.2.1 OBJECTIVE RESPONSE (OR) 
Patients will have CT/MRI scans every 9 weeks from treatment commencement up to 45 
weeks, then every 12 weeks, until disease progression. On each occasion, overall tumour 
burden will be assessed using RECIST version 1.1 (Eisenhauer et al. 2009). Best overall 
response is the best response recorded over the whole period of assessment and could be 
complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD) 
or inevaluable for response (for which reasons such as early death due to disease or early 
death due to toxicity will be specified). Objective response is the occurrence of CR or PR as 
the best overall response. Objective response will be based on responses confirmed using the 
subsequent 9 or 12-weekly scan but objective response based on unconfirmed responses will 
also be reported. 
14.1.2.2 BEST PERCENTAGE CHANGE IN SUM OF TARGET LESION DIAMETERS 
(PCSD) 
At each evaluation, the longest diameters of all selected target lesions will be measured and 
summed and the percentage change from the baseline measurement will be calculated. The 
best percentage change is the one that reflects either the greatest decrease or the least 
increase over the whole period of assessment. 
14.1.2.3 TIME TO MAXIMAL RESPONSE (TTMR) 
This is defined as the time from commencement of trial treatment to the date of CT/MRI scan 
that first records objective response as per RECIST version 1.1. Objective response is the 
occurrence of CR or PR as the best overall response. TTMR is evaluable for patients who 
achieve objective response. 
14.1.2.4 PROGRESSION-FREE SURVIVAL TIME (PFS) 
This is defined as the time from commencement of trial treatment to the date of CT/MRI scan 
when progressive disease first recorded or date of death without previously recorded 
progression. Patients who are alive with no recorded progression at the time of analysis will 
be censored at the date of the CT/MRI scan when they were last recorded with an evaluable 
measure that was not progression.  
14.1.2.5 OVERALL SURVIVAL TIME (OS) 
This is defined as the time from commencement of trial treatment to the date of death. Patients 
who are alive at the time of analysis will be censored at the date last seen alive.  
 
14.2 ANALYSIS OF OUTCOME MEASURES 
The trial will use a Bayesian analysis to determine a clinically relevant signal of effect in this 
population. A true DCB rate of at least 30% would provide sufficient proof of concept to warrant 
further research (efficacy criteria). The statistical analysis plan is to estimate a posterior 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
probability distribution for the true DCB rate given the observed trial data and a minimally-
informative prior. As well as providing estimates for the true DCB rate, the analysis will 
calculate the probability that the true DCB rate is ≥ 30%. In terms of secondary outcome 
measures, posterior probability distributions will be estimated for the true OR rate, median 
PCSD, median TTMR, median PFS and median OS. The statistical analysis plan will provide 
details of the selection of subjects to be included in the analysis in addition to procedures for 
accounting for missing, unused or spurious data. 
 
14.3 PLANNED INTERIM ANALYSES 
At the interim analysis, the trial will be recommended to stop early if p(true DCB 
rate<30%)>90%, i.e. if there is a high chance that the true signal in the targeted group falls 
below a clinically relevant threshold value (futility criteria). Secondary outcome measures will 
also be considered and contribute to this decision. The efficacy criteria will not be considered 
at interim analyses. A decision to stop early will be made in consultation with the TSC.  
 
14.4 PLANNED FINAL ANALYSES 
At the final analysis, the trial will recommend further research if p(true DCB rate≥30%) >50% 
(efficacy criteria). Secondary outcome measures will also be considered and contribute to this 
decision.  
 
14.5 SAMPLE SIZE 
Target sample size is 36 patients with an interim analysis at 18. With an expected MHC class 
II prevalence of around 10% in locally advanced or metastatic MSS CRC this will require 
screening of approximately 360 patients. It is projected that each site will enrol approximately 
four patients for trial treatment. 
The operating characteristics for this design show that there is a 9% chance of incorrectly 
recommending further research when the true DCB rate is 20% (equivalent to a type I error 
rate) and 91% chance of correctly recommending further research when the true DCB rate is 
40% (equivalent to power).  
 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 TRIAL ORGANISATIONAL STRUCTURE 
 
15.1 SPONSOR 
The trial is sponsored by The University of Birmingham. 
 
15.2 COORDINATING CENTRE 
The trial is being conducted under the auspices of the CRCTU, University of Birmingham 
according to their local procedures. 
 
15.3 TRIAL MANAGEMENT GROUP (TMG) 
A TMG will be established and as a minimum will include the Chief Investigator, Co-
Investigators, the Lead and Trial Statistician, Trial Management Team Leader and Trial 
Coordinator. Other key personnel may be invited to join the TMG as appropriate to ensure 
representation from a range of professional groups. 
Notwithstanding the legal obligations of the Sponsor and Chief Investigator, the TMG will be 
responsible for the day-to-day running and management of the trial and will meet by 
teleconference or in person as required. 
 
15.4 TRIAL STEERING COMMITTEE (TSC) 
The role of the TSC is to provide overall supervision for the trial on behalf of the Trial Sponsor 
(University of Birmingham) and to ensure that the trial is conducted to the rigorous standards 
set out in the GCP standards. In particular, the TSC will concentrate on progress of the trial, 
adherence to the protocol, patient safety, evidence on main efficacy outcome measures and 
the consideration of new information of relevance to the research question. The safety and 
well-being of the trial participants are the most important considerations and should prevail 
over the interests of science and society. The TSC will provide advice, through its Chair, to the 
Chief Investigator and the University of Birmingham on all appropriate aspects of the trial. 
Membership of the TSC includes an independent Chair and two other independent members, 
who do not sit on the TMG. The TSC will be asked to comment in detail on substantial changes 
to the protocol. The TSC will meet as often as required, at least once per year during 
recruitment. 
 
15.5 FINANCE 
This is an investigator-initiated and investigator-led trial funded by Bristol-Myers Squibb 
Pharmaceuticals Ltd. Per-patient payments will be made to NHS Trusts for research related 
costs upon receipt and validation of a completed CRF. 
Nivolumab will be provided free of charge by Bristol-Myers Squibb Pharmaceuticals Ltd. 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 ETHICAL CONSIDERATIONS 
 
The trial will be performed in accordance with the recommendations guiding physicians in 
biomedical research involving human subjects, adopted by the 18th World Medical Association 
General Assembly, Helsinki, Finland, June 1964, amended at the 48th World Medical 
Association General Assembly, Somerset West, Republic of South Africa, October 1996 
(website: http://www.wma.net/en/30publications/10policies/b3/index.html) (APPENDIX 5). 
 
The trial will be conducted in accordance with the UK Policy Framework for Health and Social 
Care Research, the applicable UK Statutory Instruments, (which include the Medicines for 
Human Use Clinical Trials 2004 and subsequent amendments, the General Data Protection 
Regulation 2016/679 and the Data Protection Act 2018, the Human Tissue Act 2004) and Good 
Clinical Practice (GCP). This trial will be carried out under a Clinical Trial Authorisation in 
accordance with the Medicines for Human Use Clinical Trials regulations. The protocol will be 
submitted to and approved by REC and Health Research Authority (HRA) prior to circulation. 
 
Before any patients are enrolled into the trial, the Principal Investigator at each site is required 
to obtain local R&D approval. Sites will not be permitted to enrol patients until written 
confirmation of R&D approval is received by the ANICCA-Class II Trial Office. 
In the case of a substantial amendment to the protocol, approval will be sought by the Sponsor 
from the REC, MHRA and HRA prior to implementation. 
 
It is the responsibility of the Principal Investigator to ensure that all amendments gain the 
necessary local approval. This does not affect the individual clinicians’ responsibility to take 
immediate action if thought necessary to protect the health and interest of individual patients. 
 
 
 CONFIDENTIALITY AND DATA PROTECTION 
Personal data recorded on all documents will be regarded as strictly confidential and will be 
handled and stored in accordance with the General Data Protection Regulation 2016/679 and 
the Data Protection Act 2018. With the patient’s consent, their date of birth (month and year 
only), National Health Service (NHS) number, or in Scotland the Community Health Index 
(CHI), hospital number will be collected at trial entry to allow tracing through national agencies 
(e.g. the Office of National Statistics and Cancer Registries) to assist with long-term follow up 
via other healthcare professionals (e.g. patient’s GP). Patients will be identified using only their 
unique TNO and initials on the CRF and correspondence between the ANICCA-Class II Trial 
Office and the participating site. However, patients are asked to give permission for the 
ANICCA-Class II Trial Office to be sent a copy of their signed Informed Consent Forms, which 
will not be anonymised. This will be used to perform in-house monitoring of the consent 
process. 
 
The Investigator must maintain documents not for submission to the ANICCA-Class II Trial 
Office (e.g. Patient Identification Logs) in strict confidence. In the case of specific issues and/or 
queries from the regulatory authorities, it will be necessary to have access to the complete trial 
records, provided that patient confidentiality is protected. 
 
The ANICCA-Class II Trial Office will maintain the confidentiality of all patients’ data and will 
not disclose information by which patients may be identified to any third party other than those 
directly involved in the treatment of the patient and organisations for which the patient has 
given explicit consent for data transfer. Representatives of the ANICCA-Class II trial team may 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
be required to have access to patient’s notes for quality assurance purposes but patients 
should be reassured that their confidentiality will be respected at all times. 
 
 
 INSURANCE AND INDEMNITY 
University of Birmingham employees are indemnified by the University insurers for negligent 
harm caused by the design or co-ordination of the clinical trials they undertake whilst in the 
University’s employment. 
In terms of liability at a site, NHS Trust and non-Trust hospitals have a duty to care for patients 
treated, whether or not the patient is taking part in a clinical trial. Compensation is therefore 
available via NHS indemnity in the event of clinical negligence having been proven. 
The University of Birmingham cannot offer indemnity for non-negligent harm. The University 
of Birmingham is independent of any pharmaceutical company, and as such it is not covered 
by the Association of the British Pharmaceutical Industry (ABPI) guidelines for patient 
compensation. 
 
 
 PUBLICATION POLICY 
Results of this trial will be submitted for publication in a peer reviewed journal. The manuscript 
will be prepared by the TMG and authorship will be determined by mutual agreement.  
Any secondary publications and presentations prepared by Investigators must be reviewed by 
the TMG. Manuscripts must be submitted to the TMG in a timely fashion and in advance of 
being submitted for publication, to allow time for review and resolution of any outstanding 
issues. Authors must acknowledge that the trial was performed with the support of the 
University of Birmingham. Intellectual Property rights will be addressed in the Clinical Site 
Study Agreement between Sponsor and site. 
 
 

 
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Tumors with Mismatch-Repair Deficiency NEJM 2015;372(26):2509-20 
2. Lal N, Beggs AD, Willcox BE, Middleton GW An immunogenomic stratification of colorectal 
cancer: Implications for development of targeted immunotherapy. OncoImmunology 
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3. Bindea G, Mlecnik B, Tosolini M, Kirilovsky A, Waldner M, Obenauf AC Spatiotemporal 
dynamics of intratumoral immune cells reveal the immune landscape in human cancer 
Immunity 2013;39(4):782-95 
4. Lal N, White BS, Goussous G, Pickles O, Mason MJ, Beggs AD, Taniere P, Willcox BE, 
Guinney J, Middleton GW KRAS mutation and consensus molecular subtypes 2 and 3 are 
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cancer  
5. Ossendorp F, Mengedé E, Camps M, Filius R, Melief CJ. Specific T helper cell requirement 
for optimal induction of cytotoxic T lymphocytes against major histocompatibility complex 
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Jan 1;24(1):224-233 
6. Ridge JP, Di Rosa F, Matzinger P A conditioned dendritic cell can be a temporal bridge 
between a CD4+ T-helper and a T-killer cell Nature 1998;393:474-8 
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specific CD4+ T cells have a major "post-licensing" role in CTL mediated anti-tumor 
immunity J Immunol 2000;165:6047-55 
8. Xie Y, Akpinarli A, Maris C, Hipkiss EL, Lane M, Kwon EK et al. Naive tumor-specific 
CD4(+) T cells differentiated in vivo eradicate established melanoma J Exp Med 
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9. Quezada SA, Simpson TR, Peggs KS, Merghoub T, Vider J, Fan X, et al. Tumor-reactive 
CD4(+) T cells develop cytotoxic activity and eradicate large established melanoma after 
transfer into lymphopenic hosts J Exp Med, 2010;207:637-50 
10. Hunder NN, Wallen H, Cao J, Hendricks DW, Reilly JZ, Rodmyre R et al. Treatment of 
metastatic melanoma with autologous CD4+ T cells against NY-ESO-1 NEJM 
2008;358:2698-703 
11. Tran E, Turcotte S, Gros A, Robbins PF, Lu YC, Dudley ME et al. Cancer immunotherapy 
based on mutation-specific CD4+ T cells in a patient with epithelial cancer Science 
2014;344:641-5 
12. Mlecnik B, Bindea G, Angell HK, Maby P, Angelova M, Tougeron D et al. Integrative 
Analyses of Colorectal Cancer Show Immunoscore Is a Stronger Predictor of Patient 
Survival Than Microsatellite Instability Immunity 2016;44(3):698-711 
13. Kreiter S, Vormehr M, van de Roemer N, Diken M, Löwer M, Diekmann J, et al. Mutant 
MHC class II epitopes drive therapeutic immune responses to cancer Nature 
2015;520(7549):692-96. 
14. Meazza R, Comes A, Orengo AM, Ferrini S, Accolla RS. Tumor rejection by gene transfer 
of the MHC class II transactivator in murine mammary adenocarcinoma cells Eur J 
Immunol 2003;33(5):1183-92 
15. Mortara L, , Castellani P, Meazza R, Tosi G, De Lerma Barbaro A, Procopio F et al. CIITA-
induced MHC class II expression in mammary adenocarcinoma leads to a Th1 polarization 
of the tumor microenvironment, tumor rejection, and specific antitumor memory. Clin 
Cancer Res 2006;12(11 Pt 1):3435-43 
16. Johnson D, Estrada MV2, Salgado R3, Sanchez V2, Doxie DB4, Opalenik SR et al. 
Melanoma-specific MHC-II expression represents a tumour-autonomous phenotype and 
predicts response to anti-PD-1/PD-L1 therapy Nature Comms 2016;7:10582  
17. Yan H, Hou X, Li T, Zhao L, Yuan X, Fu H, Zhu R. CD4+ T cell-mediated cytotoxicity 
eliminates primary tumor cells in metastatic melanoma through high MHC class II 

 
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expression and can be enhanced by inhibitory receptor blockade. Tumor Biol. 37, 15949–
15958 (2016). 
18. Roemer MGM, Redd RA, Cader FZ, Pak CJ, Abdelrahman S, Ouyang J et al. Major 
Histocompatibility Complex Class II and Programmed Death Ligand 1 Expression Predict 
Outcome After Programmed Death 1 Blockade in Classis Hodgkin Lymphoma. Journal of 
Clinical Oncology 2018 Apr 1; 36(10):942-950. 
19. Løvig T, Andersen SN, Thorstensen L, Diep CB, Meling GI, Lothe RA, Rognum TO. Strong 
HLA-DR expression in microsatellite stable carcinomas of the large bowel is associated 
with good prognosis. Br J Cancer. 2002 Sep 23;87(7):756-62. 
20. Rodig SJ, Gusenleitner D, Jackson DG, Gjini E, Giobbie-Hurder A, Jin C, Chang H, Lovitch 
SB, Horak C, Weber JS, Weirather JL, Wolchok JD, Postow MA, Pavlick AC, Chesney J, 
Hodi FS. MHC proteins confer differential sensitivity to CTLA-4 and PD-1 blockade in 
untreated metastatic melanoma. Sci Transl Med. 2018 Jul 18;10(450) 
21. Johnson DB, Nixon MJ, Wang Y, Wang DY, Castellanos E, Estrada MV, Ericsson-
Gonzalez PI, Cote CH, Salgado R, Sanchez V, Dean PT, Opalenik SR, Schreeder DM, 
Rimm DL, Kim JY, Bordeaux J, Loi S, Horn L, Sanders ME, Ferrell PB Jr, Xu Y, Sosman 
JA, Davis RS, Balko JM. Tumor-specific MHC-II expression drives a unique pattern of 
resistance to immunotherapy via LAG-3/FCRL6 engagement. JCI Insight. 2018 Dec 
20;3(24). pii: 120360 
22. Bou Nasser Eddine F, Forlani G, Lombardo L, Tedeschi A, Tosi G, Accolla RS. CIITA-
driven MHC class II expressing tumor cells can efficiently prime naive CD4+ TH cells in 
vivo and vaccinate the host against parental MHC-II-negative tumor cells. 
Oncoimmunology. 2016 Nov 28;6(1):e1261777. 
23. Overman MJ, Lonardi S, Leone F, McDermott RS, Morse MA, Wong KYM, et al. Nivolumab 
in patients with DNA mismatch repair deficient/microsatellite instability high metastatic 
colorectal cancer: Update from CheckMate 142. Journal of Clinical Oncology. 
2017;35(4_suppl):519-519. 
24. Zhao X, Ivaturi V, Gopalakrishnan M, Shen J, Feng Y, Statkevich P, Richards E, Rashford 
M, Goodman V, Gobburu J, Bello A. Abstract CT101: A model-based exposure-response 
(ER) assessment of a nivolumab (NIVO) 4-weekly (Q4W) dosing schedule across multiple 
tumor types. American Association for Cancer Research. 2017 Jul; 77(13): CT101-CT101. 
25. Chalabi M, Fanchi LF, Dijkstra KK, Van den Berg JG, Aalbers AG, Sikorska K, Lopez-
Yurda M, Grootscholten C, Beets GL, Snaebjornsson P, Maas M. Neoadjuvant 
immunotherapy leads to pathological responses in MMR-proficient and MMR-deficient 
early-stage colon cancers. Nature medicine. 2020 Apr;26(4):566-76. 
26. Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., 
Carbone, P.P. Toxicity And Response Criteria Of The Eastern Cooperative Oncology 
Group. Am J Clin Oncol 1982; 5:649-655. 
27. J. B. A. G. Haanen, F. Carbonnel C. Robert, K. M. Kerr, S. Peters, J. Larkin & K. Jordan, 
on behalf of the ESMO Guidelines Committee* 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
EASTERN COOPERATIVE ONCOLOGY GROUP PERFORMANCE 
(ECOG) STATUS26 
 
Table 5 ECOG 
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work 
of a light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all self-care but unable to carry out any work activities. 
Up and about more than 50% of waking hours 
3 
Capable of only limited self-care, confined to bed or chair more than 50% of waking 
hours 
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair 
5 
Dead 
 
 
 
COMMON TOXICITY CRITERIA GRADINGS 
 
Toxicities will be recorded according to the CTCAE, version v4.03. The full CTCAE document 
is available on the National Cancer Institute website, the following address was correct when 
this version of the protocol was approved: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
RECIST V1.1 CRITERIA 
 
RECIST version 1.1 will be used in this trial for assessment of tumour response. While either 
CT or MRI may be used, as per RECIST 1.1, CT is the preferred imaging technique in this trial. 
 
The following contains excerpts from the RECIST version 1.1 plus trial specific instructions. A 
free copy of the revised guidelines is available from 
http://www.eortc.be/Recist/documents/RECISTGuidelines.pdf 
 
Measurability of Tumour Lesions at Baseline 
Only patients with measurable disease at baseline should be included. Measurable disease is 
defined by the presence of at least one measurable lesion. At baseline, tumour lesions will be 
categorised as follows:  
• 
Measurable 
• 
Non-measurable 
Measurable lesions are those that can be accurately measured in at least one dimension 
(longest diameter to be recorded) with a minimum size of 10 mm by CT scan (CT scan slice 
thickness no greater than 5 mm), 10 mm calliper measurement by clinical exam (lesions which 
cannot be accurately measured with callipers should be recorded as non-measurable) and 20 
mm by chest X-ray. For malignant lymph nodes to be considered pathologically enlarged and 
measurable, a lymph node must be ≥15 mm in short axis when assessed by a CT scan (at 
baseline and during treatment, only the short axis will be measured and followed). 
Non-measurable lesions are all other lesions, including small lesions (longest diameter <10 
mm or pathological lymph nodes with ≥10 to >15 mm short axis) and truly non-measurable 
lesions.  
Lesions considered to be truly non-measurable include the following: bone lesions, 
leptomeningeal disease, ascites, pleural/pericardial effusion, inflammatory breast disease, 
lymphangitis cutis/pulmonis, abdominal masses that are not confirmed and followed by 
imaging techniques, and cystic lesions. 
Tumour lesions that are situated in a previously irradiated area are not considered measurable. 
The term "evaluable" in reference to measurability is not recommended and will not be used 
because it does not provide additional meaning or accuracy.  
All measurements should be recorded in metric notation using callipers (or a ruler) if clinically 
assessed. All baseline evaluations should be performed as closely as possible to the beginning 
of treatment and never more than 4 weeks before the beginning of treatment.  
 
Specifications by Methods of Measurements 
The same method of assessment and the same technique should be used to characterise each 
identified and reported lesions at baseline, during treatment and at the post-treatment 
assessment. Image-based evaluation is preferred to evaluation by clinical examination when 
both methods have been used to assess the anti-tumour effect of a treatment. CT is the best 
currently available and reproducible method for measuring target lesions selected for response 
assessment. Investigators should utilize the best available CT imaging technique available to 
them for determining response and PFS of patients participating in the ANICCA-II trial. 
 
 

 
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Tumour Response Evaluation 
 
Baseline Documentation of "Target" and "Non-target" Lesions  
All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, 
representative of all involved organs, should be identified as “target” lesions and recorded and 
measured at baseline.  
Target lesions should be selected on the basis of their size (those with the longest diameter) 
and their suitability for accurate, reproducible, repeated measurements.  
A sum of the longest diameter (LD) for all target lesions will be calculated and reported as the 
baseline sum LD. The baseline sum LD will be used as the reference by which to characterise 
the objective tumour response.  
All other lesions (or sites of disease) should be identified as “non-target” lesions and should 
also be recorded at baseline. Measurements of these lesions are not required but these lesions 
should be followed as ‘present’, ‘absent’ or in rare cases ‘unequivocal progression’ and 
recorded. 
 
Response Criteria 
 
Table 6 Evaluation of Target Lesions 
Response Category 
Description 
Complete Response (CR) 
Disappearance of all target lesions 
Partial Response (PR) 
At least a 30% decrease in the sum of the LD of target lesions, taking as reference the 
baseline sum LD 
Progressive Disease (PD) 
At least a 20% increase in the sum of the LD of target lesions, taking as reference the 
smallest sum LD recorded since the treatment started or the appearance of one or more 
new lesions. In addition to this, the sum must also demonstrate an absolute increase of 
at least 5 mm. The appearance of one or more lesion is also considered progression.  
Stable Disease (SD) 
Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, 
taking as reference the smallest sum LD since the treatment started 
 
Table 7 Evaluation of Non-target Lesions 
Response Category 
Description 
Complete Response (CR) 
Disappearance of all non-target lesions  
Incomplete Response/ 
Stable Disease (SD) 
Persistence of one or more non-target lesion(s)  
Progressive Disease (PD) 
Appearance of one or more new lesions and/or unequivocal progression of existing non-
target lesions 1  
Notes: 
1. To achieve “unequivocal progression” on the basis of the non-target disease, there must be an overall level of substantial 
worsening in non-target disease such that, even in presence of SD or PR in target disease, the overall tumour burden has 
increased sufficiently to merit discontinuation of therapy.  
 
Evaluation of Best Overall Response 
The best overall response is the best response recorded from the start of treatment until 
disease progression In general, the patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria.  
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
Overall Responses for all Possible Combinations of Tumour Responses in Target and 
Non-target Lesions With or Without the Appearance of New Lesions 
 
Table 8 Overall Response evaluation 
Target Lesions 
Non-target Lesions 
New Lesions 
Overall Response 
Complete response 
(CR) 
CR 
No 
CR 
Complete response 
(CR) 
Non-CR/non-PD 
No 
PR 
Complete response 
(CR) 
Not evaluated 
No 
PR 
Partial response (PR) 
Non-PD 
No 
PR 
Stable disease (SD) 
Non-PD 
No 
SD 
Not all evaluated 
Non-PD 
No 
Not evaluable (NE) 
Progressive disease 
(PD) 
Any 
Yes or no 
PD 
Any 
PD 
Yes or no 
PD 
Any 
Any 
Yes 
PD 
 
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be classified as having 
"symptomatic deterioration." Every effort should be made to document the objective disease 
progression, even after discontinuation of treatment. 
 
 
 

 
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DEFINITION OF ADVERSE EVENTS 
 
Adverse Event (AE) 
Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal 
product and which does not necessarily have a causal relationship with this treatment. 
Comment: 
An AE can therefore be any unfavourable and unintended sign (including abnormal laboratory 
findings), symptom or disease temporally associated with the use of an investigational 
medicinal product, whether or not related to the investigational medicinal product. 
 
Adverse Reaction (AR) 
All untoward and unintended responses to an IMP related to any dose administered. 
Comment: 
An AE judged by either the reporting Investigator or Sponsor as having causal relationship to 
the IMP qualifies as an AR. The expression reasonable causal relationship means to convey 
in general that here is evidence or argument to suggest a causal relationship. 
 
Serious Adverse Event (SAE) 
Any untoward medical occurrence or effect that at any dose: 
• 
Results in death (unrelated to cancer under study) 
• 
Is life-threatening* 
• 
Requires hospitalisation** or prolongation of existing in patients hospitalisation 
• 
Results in persistent or significant disability or incapacity 
• 
Is a congenital anomaly/birth defect 
• 
Or is otherwise considered medically significant by the Investigator*** 
For the purposes of the ANICCA-Class II trial the following are also regarded as serious 
adverse events: 
• 
A suspected transmission of an infectious agent (eg, pathogenic or non-pathogenic) via 
the trial drug 
• 
A potential drug-induced liver injury (DILI), meeting the defined criteria (see section 9.1.3) 
• 
An overdose of the trial drug 
• 
Pregnancy 
 
Comments: 
The term severe is often used to describe the intensity (severity) of a specific event. This is not 
the same as serious, which is based on patient’s/event outcome or action criteria. 
 
* Life threatening in the definition of an SAE refers to an event in which the patient was at risk 
of death at the time of the event; it does not refer to an event that hypothetically might have 
caused death if it were more severe. 
**Hospitalisation is defined as an unplanned, formal inpatient admission, even if the 
hospitalisation is a precautionary measure for continued observation. Thus hospitalisation for 
protocol treatment (e.g. line insertion), elective procedures (unless brought forward because 
of worsening symptoms) or for social reasons (e.g. respite care) are not regarded as an SAE. 

 
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*** Medical judgment should be exercised in deciding whether an AE is serious in other 
situations. Important AEs that are not immediately life threatening or do not result in death or 
hospitalisation but may jeopardise the subject or may require intervention to prevent one of the 
other outcomes listed in the definition above, should be considered serious. Examples of such 
events include, but are not limited to, intensive treatment in an emergency room or at home 
for allergic bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization. 
 
Serious Adverse Reaction (SAR) 
An Adverse Reaction which also meets the definition of a Serious Adverse Event. 
 
Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A SAR that is unexpected i.e. the nature, or severity of the event is not consistent with the 
applicable product information. 
A SUSAR should meet the definition of an AR, UAR and SAR. 
 
Unexpected Adverse Reaction (UAR) 
An AR, the nature or severity of which is not consistent with the applicable product information.  
Comments: 
When the outcome of an AR is not consistent with the applicable product information the AR 
should be considered unexpected. 
 
 

 
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WMA DECLARATION OF HELSINKI 
 
WORLD MEDICAL ASSOCIATION DECLARATION OF HELSINKI (1886 Version) 
Recommendations guiding physicians in biomedical research involving human 
subjects 
Adopted by the 18th World Medical Assembly, Helsinki, Finland, June 1964 and amended by 
the 29th World Medical Assembly, Tokyo, Japan, October 1975, 35th World Medical 
Assembly, Venice, Italy, October 1983, 41st World Medical Assembly, Hong Kong, 
September 1989 and the 48th General Assembly, Somerset West, Republic of South Africa, 
October 1996 
 
INTRODUCTION 
It is the mission of the physician to safeguard the health of the people. His or her knowledge 
and conscience are dedicated to the fulfilment of this mission. 
The Declaration of Geneva of the World Medical Association binds the physician with the 
words, "The Health of my patient will be my first consideration," and the International Code of 
Medical Ethics declares that, "A physician shall act only in the patient's interest when providing 
medical care which might have the effect of weakening the physical and mental condition of 
the patient." 
The purpose of biomedical research involving human subjects must be to improve diagnostic, 
therapeutic and prophylactic procedures and the understanding of the aetiology and 
pathogenesis of disease. 
In current medical practice most diagnostic, therapeutic or prophylactic procedures involve 
hazards. This applies especially to biomedical research. 
Medical progress is based on research which ultimately must rest in part on experimentation 
involving human subjects. 
In the field of biomedical research a fundamental distinction must be recognised between 
medical research in which the aim is essentially diagnostic or therapeutic for a patient, and 
medical research, the essential object of which is purely scientific and without implying direct 
diagnostic or therapeutic value to the person subjected to the research. 
Special caution must be exercised in the conduct of research which may affect the 
environment, and the welfare of animals used for research must be respected. 
Because it is essential that the results of laboratory experiments be applied to human beings 
to further scientific knowledge and to help suffering humanity, the World Medical Association 
has prepared the following recommendations as a guide to every physician in biomedical 
research involving human subjects. They should be kept under review in the future. It must be 
stressed that the standards as drafted are only a guide to physicians all over the world. 
Physicians are not relieved from criminal, civil and ethical responsibilities under the laws of 
their own countries. 
 
I. BASIC PRINCIPLES 
1. 
Biomedical research involving human subjects must conform to generally accepted 
scientific principles and should be based on adequately performed laboratory and animal 
experimentation and on a thorough knowledge of the scientific literature. 
2. 
The design and performance of each experimental procedure involving human subjects 
should be clearly formulated in an experimental protocol which should be transmitted for 
consideration, comment and guidance to a specially appointed committee independent of 
the Investigator and the sponsor provided that this independent committee is in conformity 
with the laws and regulations of the country in which the research experiment is performed. 
3. 
Biomedical research involving human subjects should be conducted only by scientifically 
qualified persons and under the supervision of a clinically competent medical person. The 

 
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responsibility for the human subject must always rest with a medically qualified person 
and never rest on the subject of the research, even though the subject has given his or 
her consent. 
4. 
Biomedical research involving human subjects cannot legitimately be carried out unless 
the importance of the objective is in proportion to the inherent risk to the subject. 
5. 
Every biomedical research project involving human subjects should be preceded by 
careful assessment of predictable risks in comparison with foreseeable benefits to the 
subject or to others. Concern for the interests of the subject must always prevail over the 
interests of science and society. 
6. 
The right of the research subject to safeguard his or her integrity must always be 
respected. Every precaution should be taken to respect the privacy of the subject and to 
minimize the impact of the study on the subject's physical and mental integrity and on the 
personality of the subject. 
7. 
Physicians should abstain from engaging in research projects involving human subjects 
unless they are satisfied that the hazards involved are believed to be predictable. 
Physicians should cease any investigation if the hazards are found to outweigh the 
potential benefits. 
8. 
In publication of the results of his or her research, the physician is obliged to preserve the 
accuracy of the results. Reports of experimentation not in accordance with the principles 
laid down in this Declaration should not be accepted for publication. 
9. 
In any research on human beings, each potential subject must be adequately informed of 
the aims, methods, anticipated benefits and potential hazards of the study and the 
discomfort it may entail. He or she should be informed that he or she is at liberty to abstain 
from participation in the study and that he or she is free to withdraw his or her consent to 
participation at any time. The physician should then obtain the subject's freely-given 
informed consent, preferably in writing. 
10. When obtaining informed consent for the research project the physician should be 
particularly cautious if the subject is in a dependent relationship to him or her or may 
consent under duress. In that case the informed consent should be obtained by a 
physician who is not engaged in the investigation and who is completely independent of 
this official relationship. 
11. In case of legal incompetence, informed consent should be obtained from the legal 
guardian in accordance with national legislation. Where physical or mental incapacity 
makes it impossible to obtain informed consent, or when the subject is a minor, permission 
from the responsible relative replaces that of the subject in accordance with national 
legislation. Whenever the minor child is in fact able to give a consent, the minor's consent 
must be obtained in addition to the consent of the minor's legal guardian. 
12. The research protocol should always contain a statement of the ethical considerations 
involved and should indicate that the principles enunciated in the present Declaration are 
complied with. 
 
II. MEDICAL RESEARCH COMBINED WITH PROFESSIONAL CARE (Clinical Research) 
1. 
In the treatment of the sick person, the physician must be free to use a new diagnostic 
and therapeutic measure, if in his or her judgement it offers hope of saving life, re-
establishing health or alleviating suffering. 
2. 
The potential benefits, hazards and discomfort of a new method should be weighed 
against the advantages of the best current diagnostic and therapeutic methods. 
3. 
In any medical study, every patient - including those of a control group, if any - should be 
assured of the best proven diagnostic and therapeutic method. This does not exclude the 
use of inert placebo in studies where no proven diagnostic or therapeutic method exists. 
4. 
The refusal of the patient to participate in a study must never interfere with the physician-
patient relationship. 

 
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5. 
If the physician considers it essential not to obtain informed consent, the specific reasons 
for this proposal should be stated in the experimental protocol for transmission to the 
independent committee (I, 2). 
6. 
The physician can combine medical research with professional care, the objective being 
the acquisition of new medical knowledge, only to the extent that medical research is 
justified by its potential diagnostic or therapeutic value for the patient. 
 
III. NON-THERAPEUTIC BIOMEDICAL RESEARCH INVOLVING HUMAN 
SUBJECTS (Non-Clinical Biomedical Research) 
1. 
In the purely scientific application of medical research carried out on a human being, it is 
the duty of the physician to remain the protector of the life and health of that person on 
whom biomedical research is being carried out. 
2. 
The subject should be volunteers - either healthy persons or patients for whom the 
experimental design is not related to the patient's illness. 
3. 
The Investigator or the investigating team should discontinue the research if in his/her or 
their judgement it may, if continued, be harmful to the individual. 
4. 
In research on man, the interest of science and society should never take precedence 
over considerations related to the wellbeing of the subject. 
 
 

 
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ANICCA Protocol v7.0, 01-Nov-2021 
 
 
MANAGEMENT OF TOXICITIES 
The ESMO guidelines for Management of Toxicities from immunotherapy27 will be sent as an 
electronic copy to all participating sites. A hard copy will also be provided by the trials office in 
the investigator site file for sites to use.  
The guidelines can also be found by clicking on the link below: 
 
https://www.esmo.org/Guidelines/Supportive-and-Palliative-Care/Management-of-Toxicities-
from-Immunotherapy