Randomized Phase 2 Study of Neoadjuvant Chemotherapy, Carboplatin and Paclitaxel, With or Without Atezolizumab in Triple Negative Breast Cancer (TNBC)
Phase: PHASE2
Conditions: Invasive Breast Carcinoma, Stage II Breast Cancer AJCC v6 and v7, Stage III Breast Cancer AJCC v7, Triple-Negative Breast Carcinoma
Sponsor: National Cancer Institute (NCI)

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SUMMARY OF CHANGES – Protocol 
For Protocol Amendment #6 to Amendment #7, Version #14 
NCI Protocol #: 10013 (R02, PTMA #100224) 
Local Protocol #: 201706104 
NCI Version Date: 02/28/2023 
Protocol Date: 02/28/2023 
Protocol 
Changes# Section 
Change 
1. 
Throughout 
document 
Protocol version date was updated in header. 
2. 
Title page 
Protocol version was updated. 
3. 
9 
Biomarker and Correlative Analysis plan and tissue sample 
prioritization table updated to add snRNA-seq and CODEX analyses 
4. 
9.2.3 
Immune signature section updated to include sn-RNA-seq and 
CODEX analyses for the Human Tumor Atlas Network (HTAN) 
5. 
14 
References updated throughout document to correct previous 
amendments and section 14 
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NCI Protocol #: 
10013 (R02, PTMA #100224) 
Local Protocol #: 
201706104 
ClinicalTrials.gov Identifier: NCT02883062 
TITLE: Randomized Phase 2 Study of Neoadjuvant Chemotherapy, Carboplatin and Paclitaxel, 
with or without Atezolizumab in Triple Negative Breast Cancer (TNBC) 
Corresponding Organization: LAO-CT018/Yale University Cancer Center LAO 
Principal Investigator: 
William E. Gillanders, M.D. 
Washington University School of Medicine 
660 South Euclid Avenue, Campus Box 8109 
Saint Louis, Missouri 63110 
Participating Organizations 
LAO-11030/University Health Network Princess Margaret Cancer Center LAO 
LAO-CA043/City of Hope Comprehensive Cancer Center LAO 
LAO-CT018/Yale University Cancer Center LAO 
LAO-MA036/Dana-Farber - Harvard Cancer Center LAO 
LAO-MD017/JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-MN026/Mayo Clinic Cancer Center LAO 
LAO-NJ066/Rutgers University - Cancer Institute of New Jersey LAO 
LAO-OH007/Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015/University of Pittsburgh Cancer Institute LAO 
LAO-TX035/University of Texas MD Anderson Cancer Center LAO 
LAO-NCI/National Cancer Institute LAO 
 
 
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Statistician: 
 Ph.D. 
 
Washington University School of Medicine 
 
660 S. Euclid Ave., CB 8100 
 
St. Louis, MO 63110 
 
Telephone:
 
Fax: 
 
E-mail: 
Study Coordinator: 
 
Washington University School of Medicine 
 
Telephone:
 
Fax: 
 
E-mail: 
NCI-Supplied Agent(s): Atezolizumab (MPDL3280A; NSC 783608) 
Other Agent(s): Paclitaxel (NSC 673089), Commercial; Carboplatin (NSC241240), 
Commercial 
IND #: 
 
IND Sponsor: DCTD, NCI 
Protocol Type/Version #/Version Date: Amendment #7 / Version #14 / February 28, 2023 
 
 
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STUDY SCHEMA 
 
 
 
 
This is an open label, stratified (with clinical stage as strata), randomized phase 2 clinical trial of 
neoadjuvant chemotherapy plus atezolizumab in patients with newly diagnosed clinical stage 
II/III triple neagative breast cancer. Patients will be randomized in a 1:2 ratio to carboplatin 
AUC5 q 3 weeks x 4 + paclitaxel 80 mg/m2 q week x 12 (Arm A), or carboplatin AUC5 q 3 
weeks x 4 + paclitaxel 80 mg/m2 q week x 12 + atezolizumab 1200 mg q3 weeks x 4 (Arm B). 
Tissue and peripheral blood will be collected at baseline, after the first cycle of therapy, and at 
the time of surgery. We will continue to enroll patients until there are 60 evaluable patients or 72 
total patients, whichever comes first. 
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TABLE OF CONTENTS 
STUDY SCHEMA...........................................................................................................................3 
1. 
OBJECTIVES ..........................................................................................................................6 
1.1 
Primary objective ........................................................................................................6 
1.2 
Secondary objective ....................................................................................................6 
1.3 
Exploratory objectives ................................................................................................6 
2. 
BACKGROUND ......................................................................................................................7 
2.1 
Triple-negative breast cancer ......................................................................................7 
2.2 
Atezolizumab ..............................................................................................................9 
2.3 
Study rationale ..........................................................................................................12 
2.4 
Correlative studies background .................................................................................14 
3. 
PATIENT SELECTION .........................................................................................................17 
3.1 
Eligibility criteria ......................................................................................................17 
3.2 
Exclusion criteria ......................................................................................................17 
3.3 
Inclusion of women and minorities...........................................................................20 
4. 
REGISTRATION PROCEDURES ........................................................................................21 
4.1 
Investigator and research associate registration with CTEP .....................................21 
4.2 
Site registration .........................................................................................................21 
4.3 
Patient registration ....................................................................................................23 
4.4 
Patient Randomization ..............................................................................................24 
4.5 
General guidelines ....................................................................................................24 
5. 
TREATMENT PLAN ............................................................................................................25 
5.1 
Agent administration .................................................................................................25 
5.2 
General concomitant medication and supportive care guidelines .............................28 
5.3 
Surgery ......................................................................................................................29 
5.4 
Adjuvant Treatment ..................................................................................................30 
5.5 
Specimen collection for correlative studies ..............................................................30 
5.6 
Duration of therapy ...................................................................................................32 
5.7 
Duration of follow up................................................................................................32 
5.8 
Criteria for removal from study ................................................................................32 
6. 
DOSING DELAYS/DOSE MODIFICATIONS ....................................................................33 
6.1 
Atezolizumab ............................................................................................................33 
6.2 
Systemic Chemotherapy ...........................................................................................51 
7. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS ..................................56 
7.1 
Comprehensive adverse events and potential risks list (CAEPR) ............................56 
7.2 
Adverse event characteristics ....................................................................................60 
7.3 
Expedited adverse event reporting ............................................................................61 
7.4 
Routine adverse event reporting ...............................................................................63 
7.5 
Secondary malignancy ..............................................................................................63 
7.6 
Second malignancy ...................................................................................................64 
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8. 
PHARMACEUTICAL INFORMATION ..............................................................................65 
8.1 
CTEP IND agent: Atezolizumab ..............................................................................65 
8.2 
Commercial agent: carboplatin .................................................................................67 
8.3 
Commercial agent: paclitaxel ...................................................................................68 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES .............................................70 
9.1 
Integral correlative study ..........................................................................................72 
9.2 
Exploratory correlative studies .................................................................................76 
10. STUDY CALENDAR ............................................................................................................88 
11. MEASUREMENT OF EFFECT ............................................................................................90 
11.1 Clinical response .......................................................................................................90 
11.2 Pathologic response ..................................................................................................90 
11.3 Diagnosis of breast cancer recurrence and other cancer events ................................90 
12. STUDY OVERSIGHT AND DATA REPORTING/REGULATORY REQUIREMENTS ..92 
12.1 Study oversight .........................................................................................................92 
12.2 Data reporting ...........................................................................................................92 
12.3 CTEP multicenter guidelines ....................................................................................94 
12.4 Collaborative agreements language ..........................................................................94 
12.5 Genomic data sharing plan ........................................................................................95 
13. STATISTICAL CONSIDERATIONS ...................................................................................96 
13.1 Study design/primary objective ................................................................................96 
13.2 Sample size/accrual rate ............................................................................................98 
13.3 Planned enrollment report .........................................................................................98 
13.4 Analysis of secondary endpoint ................................................................................98 
13.5 Analysis of exploratory endpoints ............................................................................99 
13.6 Reporting and exclusions ........................................................................................100 
14. REFERENCES .....................................................................................................................102 
APPENDIX A PERFORMANCE STATUS CRITERIA .........................................................110 
appendix B 
PATIENT DRUG INFORMATION HANDOUT AND WALLET CARD .....111 
 
 
 
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1. 
OBJECTIVES 
1.1 
Primary objective 
Primary objective #1 is to test the hypothesis that the combination of chemotherapy and 
atezolizumab will increase tumor infiltrating lymphocyte (TIL) percentage compared to 
chemotherapy alone in patients with newly diagnosed triple negative breast cancer (TNBC) 
being treated with neoadjuvant chemotherapy.  
TIL percentage will be measured at baseline and after initiation of therapy (day 18-22) using a 
well validated histopathologic assay. The TIL percentage after initiation of therapy will be 
compared between patients receiving neoadjuvant chemotherapy alone (Arm A) and patients 
receiving neoadjuvant chemotherapy in combination with atezolizumab (Arm B). 
Primary objective #2 is to test the hypothesis that the combination of chemotherapy and 
atezolizumab will increase the pathologic complete response (pCR) rate compared to 
chemotherapy alone in patients with newly diagnosed TNBC being treated with neoadjuvant 
chemotherapy. Pathologic complete response rates will be compared between patients receiving 
neoadjuvant chemotherapy alone (Arm A) and patients receiving neoadjuvant chemotherapy in 
combination with atezolizumab (Arm B).  
1.2 
Secondary objective 
The secondary objective is to evaluate the safety of the treatment combination of atezolizumab + 
carboplatin + paclitaxel. This will be measured by evaluation of toxicity as outlined in the 
National Cancer Institute Common Terminology Criteria for Adverse Events version 5.0. 
1.3 
Exploratory objectives 
Exploratory objective #1 is to evaluate potential biomarkers of response to chemotherapy in 
combination with atezolizumab in patients with newly diagnosed TNBC. Potential biomarkers 
include baseline TIL percentage, baseline PD-L1 expression in the tumor and tumor infiltrating 
immune cells, baseline immune signature, and baseline neoantigen load. These biomarkers will 
be correlated with pathologic complete response. 
Exploratory objective #2 is to evaluate the impact of chemotherapy in combination with 
atezolizumab on the immune response in patients with newly diagnosed TNBC. The immune 
signature and PD-L1 expression in the tumor and tumor-infiltrating immune cells will be 
evaluated at baseline and after initiation of therapy. The immune response will be correlated with 
pathologic complete response. 
Exploratory objective #3 is to evaluate the impact of chemotherapy in combination with 
atezolizumab on neoantigen-specific T cell responses in patients with newly diagnosed TNBC. 
Exploratory objective #4 is to evaluate the impact of chemotherapy in combination with 
atezolizumab on long-term clinical endpoints such as overall survival (OS) and disease-free 
survival (DFS) in patients with newly diagnosed TNBC. The correlation between long-term 
outcomes and baseline biomarkers will also be assessed. 
 
 
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2. 
BACKGROUND 
2.1 
Triple-negative breast cancer 
Triple negative breast cancer (TNBC) represents approximately 10-20% of breast cancers 
worldwide and affects approximately 200,000 women annually [1]. It is defined by a lack of 
expression of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal 
growth factor receptor 2 (HER2) receptor. The disease is more common in young black women 
and in women with a deleterious mutation in the BRCA1 gene [2, 3]. 
Established targeted therapies in breast cancer are directed against a nuclear or a surface 
receptor, such as tamoxifen or trastuzumab, respectively. However, no established targets 
currently exist for TNBC, so patients receive chemotherapy for systemic control of their disease 
[4]. Despite neoadjuvant chemotherapy trials showing that TNBC has higher pathological 
complete response (pCR) rates compared to hormone-receptor-positive subtypes [5], TNBC 
remains extremely difficult to treat in many cases, and patients have high rates of relapse, 
particularly due to chemotherapy resistance within the first few years [6]. TNBC patients suffer 
from a worse initial prognosis among all other breast cancer subtypes, and there is a dire need to 
develop new treatment strategies for TNBC, particularly for those with disease that is resistant to 
standard chemotherapy. 
2.1.1 
Neoadjuvant Chemotherapy in Triple Negative Breast Cancer 
Neoadjuvant chemotherapy describes primary systemic therapy that is utilized prior to surgery. It 
was initially used for patients with locally advanced, inoperable breast cancer in an effort to 
improve local control and decrease distant metastases when used in combination with surgery 
[7]. A few years later, the National Surgical Adjuvant Breast and Bowel Project (NSABP) began 
a clinical trial (B-18) to evaluate the efficacy of neoadjuvant chemotherapy compared to 
adjuvant therapy in patients with operable breast cancer. Approximately 1500 women were 
randomized to receive chemotherapy either pre- or post-operatively [8]. Although there were no 
survival differences or differences in rates of ipsilateral tumor recurrence after lumpectomy, 
preoperative chemotherapy led to an improvement in rates of breast conservation. Since that 
time, numerous studies have confirmed the utility of neoadjuvant chemotherapy in patients with 
locally advanced inoperable disease as well as those with operable disease who desire breast-
conserving therapy [9, 10]. In addition, the neoadjuvant platform creates an excellent model to 
assess pathologic tumor response and analyze tissue upon completion of systemic chemotherapy. 
Ultimately, this allows for the identification of molecular changes induced by treatment, and 
most importantly, it permits determination of predictors of chemotherapy resistance and 
chemotherapy sensitivity (CS) to better individualize management.  
While several clinical trials involving neoadjuvant traditional chemotherapy, biologics, or 
different dosing schedules have recently been launched in an attempt to improve the outcome of 
patients with TNBC, the initial phase of neoadjuvant studies did not restrict entry criteria to only 
patients with TNBC. However, a large proportion (41%) of the study population in NSABP 
protocol B-40 was classified as having TNBC [11]. The goals of NSABP B-40 were to determine 
if the addition of capecitabine or gemcitabine to docetaxel followed by doxorubicin and 
cyclophosphamide (AC) would increase pCR rates in patients with palpable and operable HER2-
negative disease and also to determine whether the addition of bevacizumab to docetaxel-based 
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regimens followed by AC will increase pCR rates. In the chemotherapy alone arms, the addition 
of capecitabine or gemcitabine to docetaxel versus docetaxel alone did not increase the pCR rates 
(29.7% and 31.8%, respectively, vs. 32.7%; P=0.69). Similarly, the GeparTrio study reported by 
Huober et al. showed a pCR rate of 39% in the TNBC patients in a trial that sought to determine 
the effect of switching neoadjuvant chemotherapy depending on mid-course response on pCR at 
time of surgery [12]. Patients received 2 cycles of docetaxel, doxorubicin, and 
cyclophosphamide (TAC), followed by either 4 or 6 more cycles of TAC in responders or 4 
cycles of TAC versus capecitabine plus vinorelbine in non-responders. In non-responders, pCR 
rates were less than 10% in both groups, suggesting a lack of benefit of switching chemotherapy 
to these non-standard agents or even providing further chemotherapy in the adjuvant setting to 
that subset of patients.  
2.1.2 
Platinum agents for the treatment of TNBC 
In contrast to the lack of data that capecitabine, vinorelbine or gemcitabine improve pCR rates, 
recent and increasing data indicate a potential role for platinum agents in the treatment of TNBC 
[13-16]. Sporadic BRCA mutations and/or homologous recombination DNA repair deficiency is 
known to be present in a significant fraction of TNBC patients [17-19]. This insight into the 
biology of TNBC provides strong rationale for the use of DNA damaging agents like platinum 
compounds in TNBC. Recent studies have demonstrated that the addition of carboplatin to 
anthracycline and taxane based neoadjuvant chemotherapy improves pCR rates in patients with 
TNBC, although toxicity is increased [13, 20]. 
For example, CALGB 40603, presented at the 2013 San Antonio Breast Cancer Symposium, 
evaluated the impact of the addition of carboplatin and/or bevacizumab to neoadjuvant weekly 
paclitaxel followed by dose-dense AC on pCR rates in TNBC [13]. This was a 2 X 2 factorial 
design in which patients on Arm A received weekly paclitaxel at 80 mg/m2 for 12 weeks 
followed by dose dense AC for 4 cycles, patients on Arm B received weekly paclitaxel 80 mg/m2 
for 12 weeks plus bevacizumab followed by dose dense AC for 4 cycles, patients on Arm C 
received weekly paclitaxel 80 mg/m2 for 12 weeks plus carboplatin followed by dose dense AC 
for 4 cycles, and patients on Arm D received weekly paclitaxel 80 mg/m2 for 12 weeks plus 
carboplatin and bevacizumab followed by dose dense AC for 4 cycles. While there was no clear 
benefit from the addition of bevacizumab, pCR rates increased from 41% to 54% in patients 
receiving carboplatin. Similarly, a significant improvement in pCR rate (58.7% vs 37.9%, 
p<0.05) in TNBC was observed with the addition of carboplatin (AUC 1.5 weekly) to 18 weeks 
of weekly paclitaxel (80mg/m2) plus non-pegylated liposomal doxorubicin (20mg/m2) in the 
GeparSixto trial [20].  
Kern et al. recently reported that carboplatin plus docetaxel alone is a safe and effective 
neoadjuvant chemotherapy regimen for TNBC. Patients were treated with six cycles of docetaxel 
(75 mg/m2) and carboplatin AUC 6 q3w. Grade 3/4 toxicities were rare, and 93% of patients 
completed six cycles of therapy. The pCR rate was 50%. After 2 and 5 years, overall survival 
(OS) was 96.7 and 89.7% [21, 22].  
Similarly, Sharma et al. recently reported on 190 patients with stage I-III TNBC treated 
uniformly with carboplatin and docetaxel in two independent prospective cohorts 
(NCT02489448, NCT01560663) [23]. In these cohorts, the pathologic complete response rate 
was 55%, and response rates were similar between patients with BRCA mutation-associated and 
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wildtype TNBC. Based on these promising results, a randomized phase 2 trial has been initiated 
(NCT02413320) comparing carboplatin + docetaxel alone to carboplatin + docetaxel followed by 
ddAC.  
Of note, the combination of carboplatin and paclitaxel has proven safe in combination with 
atezolizumab in NSCLC as reported at ASCO 2015 (Abstract 8030).  
Given the promising results of neoadjuvant carboplatin and docetaxel in several independent 
phase 1 clinical trials, the fact that this regimen is now being tested in a phase 2 trial, and the fact 
that carboplatin and paclitaxel has proven to be safe in combination with atezolizumab, we have 
selected carboplatin and paclitaxel as the chemotherapy backbone for this clinical trial. 
2.2 
Atezolizumab 
Atezolizumab is a human immunoglobulin (Ig) G1 monoclonal antibody consisting of two heavy 
chains (448 amino acids) and two light chains (214 amino acids) and is produced in Chinese 
hamster ovary cells [24]. Atezolizumab was engineered to eliminate Fc-effector function via a 
single amino acid substitution (asparagine to alanine) at position 298 on the heavy chain, which 
results in a non-glycosylated antibody that has minimal binding to Fc receptors and prevents Fc-
effector function at expected concentrations in humans. Atezolizumab targets human 
programmed death-ligand 1 (PD-L1) and inhibits its interaction with its PD-L1 and its receptors, 
PD-1 and B7-1 (also known as CD80), both of which function as inhibitory receptors expressed 
on T cells. 
Atezolizumab shows anti-tumor activity in both nonclinical models and cancer patients and is 
being investigated as a potential therapy in a wide variety of malignancies.  Atezolizumab is 
being studies as a single agent in the advanced cancer and adjuvant therapy settings, as well as in 
combination with chemotherapy, targeted therapy, and cancer immunotherapy. 
Atezolizumab is approved in the United States for the treatment of locally advanced or metastatic 
urothelial carcinoma and as well as metastatic non-small cell lung carcinoma. 
2.2.1 
Atezolizumab mechanism of action 
PD-L1 expression is prevalent in many human tumors (e.g., lung, bladder, ovarian, melanoma, 
colon carcinoma), and its overexpression has been associated with poor prognosis in patients 
with several cancers [25-28]. PD-L1 binds to two known inhibitory receptors expressed on 
activated T cells (PD-1 and B7.1), and receptor expression is sustained in states of chronic 
stimulation such as chronic infection or cancer [29, 30]. Ligation of PD-L1 with PD-1 or B7.1 
inhibits T-cell proliferation, cytokine production, and cytolytic activity, leading to the functional 
inactivation or inhibition of T cells. Aberrant expression of PD-L1 on tumor cells has been 
reported to impede anti-tumor immunity, resulting in immune evasion [31]. Therefore, 
interruption of the PD-L1/PD-1 and PD-L1/B7.1 pathway represents an attractive strategy to 
reinvigorate tumor-specific T-cell immunity. 
Blockade of PD-L1 or PD-1 with monoclonal antibodies has been reported to result in strong and 
often rapid antitumor effects in several mouse tumor models [32, 33]. These data suggest that 
tumor-specific T cells may be present in the tumor microenvironment in an inactive or inhibited 
state, and blockade of the PD-L1/PD-1 pathway can reinvigorate tumor-specific T-cell 
responses. 
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Collectively, these data establish the PD-L1/PD-1 pathway as a promising new therapeutic target 
in patients with advanced tumors. Immune-related adverse events (AEs) reported from the two 
recent studies were consistent with the role of the PD-L1/PD-1 pathway in regulating peripheral 
tolerance. 
2.2.2 
Summary of nonclinical experience 
The safety, pharmacokinetics (PK), and toxicokinetics of atezolizumab were investigated in mice 
and cynomolgus monkeys to support intravenous (IV) administration and to aid in projecting the 
appropriate starting dose in humans. Given the similar binding of atezolizumab for cynomolgus 
monkey and human PD-L1, the cynomolgus monkey was selected as the primary and relevant 
nonclinical model for understanding the safety, PK, and toxicokinetics of atezolizumab.  
Overall, the nonclinical PK and toxicokinetics observed for atezolizumab supported entry into 
clinical studies, including providing adequate safety factors for the proposed phase 1 starting 
doses. The results of the toxicology program were consistent with the anticipated pharmacologic 
activity of down-modulating the PD-L1/PD-1 pathway and supported entry into clinical trials in 
patients. 
Refer to the Atezolizumab Investigator’s Brochure for details on the nonclinical studies. 
2.2.3 
Summary of clinical experience 
A summary of clinical data from company-sponsored atezolizumab trials is presented below. 
Details of all ongoing studies can be found in the Atezolizumab Investigator’s Brochure. 
 
Clinical PK and immunogenicity 
On the basis of available preliminary PK data (0.03−20 mg/kg), atezolizumab shows linear PK at 
doses ≥1 mg/kg [24].  Based on an analysis of exposure, safety, and efficacy data, the following 
factors had no clinically relevant effect: age (21−89 years), body weight, gender, positive ATA 
status, albumin levels, tumor burden, region or ethnicity, renal impairment, mild hepatic 
impairment, level of PD-L1 expression, or ECOG status.  No formal PK drug-drug interaction 
studies have been conducted with atezolizumab, and the interaction potential is unknown.  
Further details can be found in the current Investigator’s Brochure. 
The development of anti-therapeutic antibodies (ATAs) has been observed in patients in all dose 
cohorts and was associated with changes in PK for some patients in the lower dose cohorts (0.3, 
1, and 3 mg/kg) [24]. Patients dosed at ≥ 10 mg/kg maintained Cmin values well above the target 
serum concentration of 6 mcg/mL  despite the detection of ATAs. Accordingly, the development 
of detectable ATAs does not appear to have a clinically significant impact on PK for doses above 
10 mg/kg. To date, no relationship between the development of measurable ATAs and safety or 
efficacy has been observed. 
 
Clinical safety summary 
As of 10 May 2016, atezolizumab has been administered (alone or in combination with other 
agents) to approximately 6053 patients with solid tumor and hematologic malignancies. The 
first-in-human monotherapy study PCD4989g (in patients with locally advanced or metastatic 
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solid tumors or hematologic malignancies) provides the majority of monotherapy safety data, 
with 629 safety-evaluable patients as of the data extraction date.  Currently, no maximum 
tolerated dose (MTD), no dose-limiting toxicities (DLTs), and no clear dose-related trends in the 
incidence of AEs have been determined. 
Fatigue, decreased appetite, nausea, diarrhea, constipation, and cough were commonly reported 
AEs in single and combination therapy (Investigator’s Brochure, 2016).  AE profiles are similar 
across tumor types studied, including non-small cell lung cancer (NSCLC), renal cell carcinoma 
(RCC), triple-negative breast cancer (TNBC), and urothelial carcinoma (UC), and are consistent 
with the mechanism of action of atezolizumab.  The overall immune-mediated AEs reported 
were considered moderate in severity, and the majority of patients were able to continue on 
atezolizumab therapy. 
As of the data extraction date of December 15, 2015, there were 629 safety-evaluable patients 
from the first-in-human phase 1a study PCD4989g (Investigator’s Brochure, 2016).  The median 
age was 61 years.  Of the 629 patients, 619 patients (98.4%) reported at least one AE of any 
grade or attribution to atezolizumab, and 316 patients (50.2%) experienced at least one grade 3 
or 4 AE of any attribution.  A total of 444 patients (70.6%) reported at least one treatment-related 
AE, and 86 patients (13.7%) experienced at least one treatment-related grade 3 or 4 AE.  The 
most frequently observed AEs of any grade and attribution (occurring in ≥10% of treated 
patients) include fatigue, decreased appetite, nausea, pyrexia, constipation, cough, dyspnea, 
diarrhea, anemia, vomiting, asthenia, back pain, headache, arthralgia, pruritus, rash, abdominal 
pain, insomnia, peripheral edema, and dizziness. 
Serious AEs (SAEs) have been reported in 261 patients (41.5%) in study PCD4989g 
(Investigator’s Brochure, 2016).  Reported SAEs were consistent with the underlying disease.  
Treatment-related SAEs (57 patients [9.1%]) included pyrexia, dyspnea, pneumonitis, malaise, 
fatigue, hypoxia, colitis, and bone pain.  Pooled single-agent safety data from 1978 patients with 
UC, NSCLC, and other indications (including trial PCD4989g) indicate that the most frequent 
(>1% of patients) serious adverse drug reactions (regardless of grade) include dyspnea (3.0%), 
back pain (1.2%), and abdominal pain (1.1%).  A list of AEs considered “expected” for 
atezolizumab is presented in Section 7.1.1. 
Immune-Related Adverse Events 
Given the mechanism of action of atezolizumab, events associated with inflammation and/or 
immune-related adverse events are closely monitored during the atezolizumab clinical program. 
To date, immune-related adverse events associated with atezolizumab include hepatitis, 
pneumonitis, colitis, pancreatitis, diabetes mellitus, hypothyroidism, hyperthyroidism, adrenal 
insufficiency, Guillain-Barré syndrome, myasthenic syndrome/myasthenia gravis, and 
meningoencephalitis. 
For further details, see the most recent Atezolizumab Investigator’s Brochure. 
 
Clinical efficacy summary 
Patients with multiple tumor types were included in study PCD4989g, with the largest cohorts 
consisting of patients with non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), and 
bladder cancer [24]. Objective responses with atezolizumab monotherapy were observed in a 
broad range of malignancies, including NSCLC, RCC, and UC. Objective responses were 
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observed in a broad range of malignancies, including NSCLC, RCC, melanoma, UC, colorectal 
cancer, head and neck cancer, gastric cancer, breast cancer, and sarcoma.   Both the preliminary 
and more mature efficacy data available suggest that treatment with atezolizumab as a single 
agent or in combination with other therapeutic agents results in anti-tumor activity across a range 
of tumor types and hematologic malignancies (UC, NSCLC, RCC, TNBC, melanoma, CRC, and 
NHL) and across lines of therapy.  Clinical benefit was observed in terms of objective responses, 
durability of responses, and overall survival (OS).  Improved efficacy of atezolizumab was 
observed in the unselected patient population, as well as in patients with higher PD-L1 
expression on TCs or ICs (e.g., NSCLC) or on ICs only (e.g., mUC, RCC).[34, 35] 
2.3 
Study rationale 
2.3.1 
Rationale for checkpoint blockade therapy in TNBC 
There is strong rationale for the use of checkpoint blockade therapy in patients with TNBC. 
First, TNBC is a mutationally complex breast cancer subtype. Previous studies suggest that 
response to checkpoint blockade therapy is associated with mutational load [36]. Several recent 
studies have provided insight into the mutational landscape in human breast cancer, including 
TNBC. While the average somatic mutational frequency across almost 30 different types of 
cancer is approximately one mutation/megabase, the frequency among all breast cancers ranges 
from 0.1 to 10 [37-39]. One feature of TNBC is the increased frequency of germline and somatic 
TP53 and BRCA1 mutations [40]. TP53 and BRCA mutations lead to defects in DNA repair 
mechanisms, and consequently an increased mutational frequency. Extensive analysis of the 
clonal and mutational spectrum of primary TNBC suggests that TNBC is characterized by a 
higher mutational frequency than other subtypes of breast cancer [41-43]. The relative 
abundance of somatic mutations in TNBC compared to other breast cancer subtypes suggests 
that neoantigens that can be targeted by checkpoint blockade therapy are more likely to be 
present. 
Second, tumor infiltrating lymphocytes (TILs) are more common in TNBC, and TILs are 
associated with improved outcome in TNBC following adjuvant or neoadjuvant chemotherapy 
[44-46]. The association between TILs and improved outcome in TNBC suggests that the 
adaptive immune system contributes to the response to chemotherapy. 
Third, PD-L1 expression is higher in TNBC than other breast cancer subtypes [47, 48]. PD-L1 
expression has been used as a biomarker for response to checkpoint blockade therapy [35]. We 
have examined the expression of PD-1 and PD-L1 in the common molecular subtypes of breast 
cancer using a well annotated human breast cancer tissue array [48, 49]. These studies 
demonstrate that expression of PD-1 on tumor-infiltrating lymphocytes and/or PD-L1 on breast 
cancers is more common in TNBC, and expression of these proteins is associated with a poor 
prognosis. Other investigators have also documented increased expression of PD-L1 in TNBC 
[47]. 
Fourth, a recent phase 1 clinical trial of atezolizumab in patients with metastatic TNBC 
demonstrates the safety of checkpoint blockade therapy with promising response rates. In an oral 
presentation at the AACR Annual meeting in April, 2015 (Abstract 2859), Emens et al. reported 
on 54 patients with metastatic TNBC enrolled in an expansion cohort. Patients received 
atezolizumab at 15 mg/kg, 20 mg/kg or 1200 mg flat dose IV q3w. AEs occurred in 67% of 
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patients, most frequently fatigue (22%), pyrexia (15%), neutropenia (15%) and nausea (15%). 
Grade 3 AEs occurred in 11% of patients (adrenal insufficiency, neutropenia, nausea, vomiting, 
decreased WBC count). Twenty-one of the 54 patients were evaluable for efficacy, all of whom 
were PDL1–positive (IHC 2/3). Among the 21 evaluable patients with PD-L1-expressing tumors, 
the unconfirmed RECIST ORR was 24% (95% CI, 8% to 47%) which included 3 PRs and 2 
CRs. Adams et al. reported the results of a phase 1b clinical trial of atezolizumab in combination 
with nab-paclitaxel in patients with metastatic TNBC at the 2015 SABCS Meeting (Abstract P2-
11-06). 24 patients with a minimum follow-up of ≥ 3 months were evaluable for efficacy. Across 
all groups the ORR was 71%. Based on these results, a randomized phase 3 trial is planned 
(IMpassion130, NCT02425891). 
2.3.2 
Rationale for the combination of chemotherapy and checkpoint blockade 
therapy 
Multiple preclinical studies and a recent phase 1 clinical trial provide strong rationale for 
combining chemotherapy and checkpoint blockade therapy. Chemotherapies have immune 
adjuvant properties. Several mechanisms have been proposed to explain how chemotherapies 
impact antitumor immunity, including modulation of STAT signaling, induction of immunogenic 
cancer cell death, and modulation of PD-L1 expression [50, 51]. Of note, several recent high 
impact publications using cell depletion or genetic models suggest that an intact adaptive 
immune system is required for the success of chemotherapy [52-54]. 
Of note, there is strong circumstantial evidence documenting the importance of the adaptive 
immune system in the response to chemotherapy in TNBC. Translational studies demonstrate 
that the presence of TILs in TNBC is strongly associated with response to chemotherapy. This 
association has been demonstrated by several independent groups using well validated 
immunohistochemistry assays and clinical specimens from large randomized prospective phase 3 
trials (BIG 02-98, ECOG E2197, ECOG E1199) [44, 45]. This association between the presence 
of TILs and response to chemotherapy has been confirmed in the neoadjuvant setting 
(GeparSixto) [46]. Similar results have been obtained when evaluating the impact of TIL 
percentage after neoadjuvant chemotherapy [55-57]. 
Preclinical studies have specifically addressed the potential of combination chemotherapy and 
checkpoint blockade. Lesterhuis et al. demonstrated that CTLA-4 blockade is synergistic with 
gemcitabine in two non-immunogenic murine tumor models [58]. Jure-Kunkel et al. 
demonstrated that CTLA-4 blockade is synergistic with ixabepilone, etoposide, and gemcitabine 
in multiple preclinical murine tumor models, including SA1N fibrosarcoma, EMT-6 mammary 
carcinoma, M109 lung carcinoma, and CT-26 colon carcinoma [59]. Shalapour et al. recently 
published a high impact paper demonstrating that anti-PDL1 therapy enhances the efficacy of 
oxaliplatin chemotherapy in prostate cancer [53]. 
A recent phase 1 clinical trial in NSCLC confirms the potential of combination chemotherapy 
and atezolizumab therapy. In an oral presentation at the ASCO Annual meeting in June, 2015 
(Abstract 8030), Liu et al. reported on 37 patients with locally advanced or metastatic NSCLC 
who were randomized to receive carboplatin-based chemotherapy regimens in combination with 
atezolizumab. Atezolizumab was given concurrently with chemotherapy, and no unexpected 
toxicities were observed. Across all arms, the ORR was 67% - significantly higher than previous 
experience with atezolizumab alone. The combination of carboplatin, paclitaxel and 
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atezolizumab has now progressed to a phase 3 trial in NSCLC (NCT02367794). 
2.4 
Correlative studies background 
2.4.1 
Tumor infiltrating lymphocyte (TIL) percentage 
TIL percentage is a well-described and validated histopathologic analysis that has been 
correlated with clinical response to adjuvant and neoadjuvant chemotherapy in patients with 
TNBC [44-46]. These studies used standardized methodology for visual assessment of TIL 
percentage, and tissue specimens from patients enrolled in phase 3 randomized clinical trials. 
The studies demonstrated that TIL percentage is associated with improved overall survival. This 
correlation was first reported using baseline samples from the BIG 2–98 trial [45] and 
subsequently independently confirmed in 481 TNBC sample prospectively collected during two 
phase III adjuvant randomized breast cancer trials (United States Eastern Cooperative Oncology 
Group trials 2197 and 1199) [44].  
An increase in the number of TILs has also been shown to be associated with response to 
checkpoint inhibition therapy in multiple independent studies. For instance, in a prospective 
randomized trial of ipilimumab for patients with advanced melanoma where serial tumor 
biopsies were obtained, Hamid et al. demonstrated that 57.1% of patients in the benefit group 
had a post-treatment increase in TILs, whereas only 10.0% of patients in the non-benefit group 
had a post-treatment increase in TILs (p = 0.005) [60]. Similarly, Tumeh et al. studied tumor 
samples from 46 patients with metastatic melanoma obtained before and after therapy with 
pembrolizumab. In this study, they used quantitative immunohistochemistry to evaluate the 
number of CD8 T cells present in the tumor and observed that an increase in the number of CD8 
T cells was strongly associated with the best percent change in tumor size as measured by CT 
scan (n=18, Spearman r = −0.75, P = 0.0002) [61]. Finally, Herbst et al. evaluated the safety, 
activity and biomarkers of PD-L1 inhibition in patients treated with atezolizumab [35]. They 
found that after atezolizumab treatment, regressing lesions displayed a dense immune 
infiltratePD-L1 expression. 
2.4.2 
PD-L1 expression 
Immune cell PD-L1 expression has recently been shown to predict response to atezolizumab 
therapy in multiple cancer types [35]. Subsequent studies of PD-L1 expression, including several 
that were performed in patients with TNBC, indicate that expression of PD-L1 should be 
assessed separately on tumor cells and tumor infiltrating immune cells [62, 63]. For example, 
Beckers et al. observed that PD-L1 was expressed by both TNBC cells and tumor infiltrating 
immune cells, and that cytoplasmic tumoral PD-L1 expression as well as stromal PD-L1 
expression was associated with favorable patient outcome. Further study is clearly required to 
define the association between PD-L1 expression and clinical response to atezolizumab in 
patients with TNBC. 
One of the exploratory objectives is to evaluate potential biomarkers of response to combination 
therapy with chemotherapy and atezolizumab in patients with newly diagnosed TNBC. We will 
correlate baseline PD-L1 expression in tumor infiltrating immune cells and/or tumor cells with 
pathologic complete response in patients being treated with combination therapy. 
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2.4.3 
Immune signature 
One of the exploratory objectives is to evaluate potential biomarkers of response to combination 
therapy with chemotherapy and atezolizumab in patients with newly diagnosed TNBC. Immune 
signature analysis will be performed using the NanoString platform. We will correlate immune 
signature at baseline with pathologic complete response in patients being treated with 
combination therapy. In addition, we will assess the change in immune signature following 
therapy. Immune signature analyses will be performed at baseline, after initiation of therapy (day 
18-22), and at time of surgery. 
Denkert et al. defined an immune signature correlated with pathologic complete response 
following neoadjuvant chemotherapy in the GeparSixto clinical trial. Twelve immunologically 
relevant mRNA markers were selected for detailed evaluation in breast cancer tissue, including 
T-cell markers, B-cell markers, chemokines, and immune checkpoint parameters (CXCL9, 
CCL5, CD8A, CD80, CXCL13, IGKC, CD21, IDO1, PD-1, PD-L1, CTLA4, FOXP3). Three 
different immune subtypes of tumors with different expression of immunologic genes were 
defined. 
Likewise, gene expression analyses have been performed in an attempt to define biomarkers of 
response to atezolizumab in NSCLC and bladder cancer [64, 65]. In NSCLC, B- and NK-cell 
signatures were associated with clinical benefit [64]. 
In bladder cancer, baseline immune signature associated with an effector T cell signature 
(including CD8A, GZMA, IFNG) and/or NK gene signature (NKG2 family members) were 
associated with clinical benefit [65]. 
2.4.4 
Neoantigen Load 
Neoantigen load has been correlated with response to checkpoint blockade therapy in preclinical 
models [66] and human clinical trials [36]. 
To estimate neoantigen load we will use recently developed sequencing and epitope prediction 
pipelines [66]. 
One of the exploratory objectives is to evaluate potential biomarkers of response to combination 
therapy with chemotherapy and atezolizumab in patients with newly diagnosed TNBC. We will 
correlate baseline neoantigen load with pathologic complete response in patients being treated 
with combination therapy. 
2.4.5 
Neoantigen-specific T cell response 
We recently described a strategy to identify and prioritize neoantigens in murine sarcomas [66]. 
We used this strategy to demonstrate that checkpoint blockade therapy targets neoantigens [66]. 
To evaluate the T cell response to multiple different candidate neoantigens, a high throughput 
assay system is required, and we have collaborated with Dr.
and 
 at The Netherlands Cancer Institute in Amsterdam to develop bar-coded MHC 
class I tetramers by UV-induced epitope exchange capable of recognizing multiple different 
neoantigen-specific T cells simultaneously. We will then identify candidate neoantigens using 
the optimized sequencing and epitope prediction algorithms that we have established. Once we 
have identified and prioritized neoantigens, we will generate MHC class I tetramers by UV-
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induced epitope exchange, and perform multiparameter flow cytometry, or time-of-flight mass 
spectrometry (CyTOF) to determine if neoantigen-specific T cells are present/functional in the 
peripheral blood or primary breast cancers.  
 
 
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3. 
PATIENT SELECTION 
3.1 
Eligibility criteria 
1. Patients must have histologically confirmed new diagnosis of breast cancer. 
2. ER and PR < Allred score of 3 or ≤ 5% positive staining cells in the invasive component 
of the tumor (provided the patient is being treated as triple negative breast cancer). 
3. HER2 negative by FISH or IHC staining 0 or 1+ according to NCCN guidelines. 
4. Clinical stage T2-T4c, any N, M0 primary tumor by AJCC 7th edition clinical staging. 
5. Eligible for neoadjuvant chemotherapy. 
6. No prior therapy for this disease. 
7. Age ≥ 18 years.  
8. ECOG performance status ≤ 2 (Karnofsky ≥ 60%, see Appendix A). 
9. Patients must have normal organ and marrow function as defined below: 
− 
leukocytes 
≥ 2,500/mcL 
− 
absolute neutrophil count 
≥ 1,500/mcL 
− 
platelets 
≥ 150,000/mcL 
− 
hemoglobin 
≥ 10 g/dL 
− 
total bilirubin 
≤ 1.5 × institutional upper limit of normal (ULN) 
(however, patients with known Gilbert disease who 
have serum bilirubin level ≤3 × ULN may be enrolled) 
− 
AST(SGOT)/ALT(SGPT) 
≤ 3 × ULN  
− 
alkaline phosphatase   
≤ 2.5 × ULN  
− 
creatinine clearance 
≥ 30 mL/min/1.73 m2 by Cockcroft-Gault: 
(140 − age) × (weight in kg) × (0.85 if female) 
72 × (serum creatinine in mg/dL) 
− 
INR and aPTT 
≤ 1.5 × ULN (This applies only to patients who do not 
receive therapeutic anticoagulation; patients receiving 
therapeutic anticoagulation, such as low-molecular-
weight heparin or warfarin, should be on a stable dose. 
10. Administration of atezolizumab may have an adverse effect on pregnancy and poses a 
risk to the human fetus, including embryo-lethality. Women of child-bearing potential 
and men must agree to use adequate contraception (hormonal or barrier method of birth 
control; abstinence) prior to study entry, for the duration of study participation, and for 
180 days after the last dose of paclitaxel. Should a woman become pregnant or suspect 
she is pregnant while she or her partner is participating in this study, she should inform 
her treating physician immediately.  
11. Ability to understand and the willingness to sign an IRB-approved written informed 
consent document. 
3.2 
Exclusion criteria 
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1. Known metastatic disease. 
2. Invasive cancer in the contralateral breast. 
3. Patients with a previous history of non-breast malignancy are eligible only if they meet 
the following criteria for a cancer survivor: (1), and (2)  
• Has undergone potentially curative therapy for all prior malignancies. 
• Has been considered disease-free for at least 1 year (with the exception of basal 
cell or squamous cell carcinoma of the skin or carcinoma-in-situ of the cervix. 
4. Patients with prior allogeneic bone marrow transplantation or prior solid organ 
transplantation. 
5. Treatment with any other investigational agent within 4 weeks prior to Cycle 1, Day 1. 
6. Treatment with systemic immunosuppressive medications (including, but not limited to, 
prednisone, cyclophosphamide, azathioprine, methotrexate, thalidomide, and anti-tumor 
necrosis factor [anti-TNF] agents) within 2 weeks prior to Cycle 1, Day 1. 
• Patients who have received acute, low dose, systemic immunosuppressant 
medications (e.g., a one-time dose of dexamethasone for nausea) may be enrolled. 
• The use of inhaled corticosteroids and mineralocorticoids (e.g., fludrocortisone) 
for patients with orthostatic hypotension or adrenocortical insufficiency is 
allowed. 
7. Patients taking bisphosphonate therapy for symptomatic hypercalcemia. Use of 
bisphosphonate therapy for other reasons (e.g., osteoporosis) is allowed. 
8. Known hypersensitivity to Chinese hamster ovary cell products or other recombinant 
human antibodies. 
9. History of severe allergic, anaphylactic, or other hypersensitivity reactions to chimeric or 
humanized antibodies or fusion proteins 
10. History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to other agents used in study. 
11. Known clinically significant liver disease, including active viral, alcoholic, or other 
hepatitis; cirrhosis; fatty liver; and inherited liver disease. 
• Patients with past or resolved hepatitis B infection (defined as having a negative 
hepatitis B surface antigen [HBsAg] test and a positive anti-HBc [antibody to 
hepatitis B core antigen] antibody test) are eligible. 
• Patients positive for hepatitis C virus (HCV) antibody are eligible only if 
polymerase chain reaction (PCR) is negative for HCV RNA. 
12. History or risk of autoimmune disease, including, but not limited to, systemic lupus 
erythematosus, rheumatoid arthritis, inflammatory bowel disease, vascular thrombosis 
associated with antiphospholipid syndrome, Wegener’s granulomatosis, Sjögren’s 
syndrome, Bell’s palsy, Guillain-Barré syndrome, multiple sclerosis, autoimmune thyroid 
disease, vasculitis, or glomerulonephritis. 
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• Patients with a history of autoimmune hypothyroidism on a stable dose of thyroid 
replacement hormone may be eligible. 
• Patients with controlled Type 1 diabetes mellitus on a stable insulin regimen may 
be eligible. 
• Patients with eczema, psoriasis, lichen simplex chronicus of vitiligo with 
dermatologic manifestations only (e.g., patients with psoriatic arthritis would be 
excluded) are permitted provided that they meet the following conditions: 
o Patients with psoriasis must have a baseline ophthalmologic exam to rule 
out ocular manifestations 
o Rash must cover less than 10% of body surface area (BSA) 
o Disease is well controlled at baseline and only requiring low potency topical 
steroids (e.g., hydrocortisone 2.5%, hydrocortisone butyrate 0.1%, 
flucinolone 0.01%, desonide 0.05%, aclometasone dipropionate 0.05%) 
o No acute exacerbations of underlying condition within the last 12 months 
(not requiring psoralen plus ultraviolet A radiation [PUVA], methotrexate, 
retinoids, biologic agents, oral calcineurin inhibitors; high potency or oral 
steroids) 
13. History of idiopathic pulmonary fibrosis, pneumonitis (including drug induced), 
organizing pneumonia (i.e., bronchiolitis obliterans, cryptogenic organizing pneumonia, 
etc.), or evidence of active pneumonitis on screening chest computed tomography (CT) 
scan. History of radiation pneumonitis in the radiation field (fibrosis) is permitted. 
14. Patients with active tuberculosis (TB) are excluded. 
15. Severe infections within 4 weeks prior to Cycle 1, Day 1, including, but not limited to, 
hospitalization for complications of infection, bacteremia, or severe pneumonia. 
16. Signs or symptoms of infection within 2 weeks prior to Cycle 1, Day 1. 
17. Received oral or intravenous (IV) antibiotics within 2 weeks prior to Cycle 1, Day 1. 
Patients receiving prophylactic antibiotics (e.g., for prevention of a urinary tract infection 
or chronic obstructive pulmonary disease) are eligible. 
18. Major surgical procedure within 28 days prior to Cycle 1, Day 1 or anticipation of need 
for a major surgical procedure during the course of the study with the exception of the 
planned breast cancer surgery that is part of the trial design. 
19. Administration of a live, attenuated vaccine within 4 weeks before Cycle 1, Day 1 or 
anticipation that such a live, attenuated vaccine will be required during the study and up 
to 5 months after the last dose of atezolizumab. 
• Influenza vaccination should be given during influenza season only 
(approximately October to March). Patients must not receive live, attenuated 
influenza vaccine within 4 weeks prior to Cycle 1, Day 1 or at any time during the 
study. 
20. Patients requiring treatment with a RANKL inhibitor (e.g. denosumab) who cannot 
discontinue it before treatment with atezolizumab. 
21. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
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symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia 
(including symptomatic sinus bradycardia), or psychiatric illness/social situations that 
would limit compliance with study requirements. 
22. Patients positive for human immunodeficiency virus (HIV) are NOT excluded from this 
study, but HIV-positive patients must have: 
• A stable regimen of highly active anti-retroviral therapy (HAART) 
• No requirement for concurrent antibiotics or antifungal agents for the prevention 
of opportunistic infections 
• A CD4 count above 250 cells/mcL and an undetectable HIV viral load on 
standard PCR-based tests 
23. Pregnant women are excluded from this study because atezolizumab is an agent with the 
potential for teratogenic or abortifacient effects. Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with atezolizumab, breastfeeding should be discontinued if the mother is treated with 
atezolizumab. These potential risks may also apply to other agents used in this study. 
3.3 
Inclusion of women and minorities 
This trial is open to women and members of all minority groups. Men will not be eligible as 
breast cancer occurs primarily in women. 
NIH policy requires that women and members of minority groups and their subpopulations be 
included in all NIH-supported biomedical and behavioral research projects involving NIH-
defined clinical research unless a clear and compelling rationale and justification establishes to 
the satisfaction of the funding Institute & Center (IC) Director that inclusion is inappropriate 
with respect to the health of the subjects or the purpose of the research. Exclusion under other 
circumstances must be designated by the Director, NIH, upon the recommendation of an IC 
Director based on a compelling rationale and justification. Cost is not an acceptable reason for 
exclusion except when the study would duplicate data from other sources. Women of 
childbearing potential should not be routinely excluded from participation in clinical research. 
Please see http://grants.nih.gov/grants/funding/phs398/phs398.pdf. 
 
 
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4. 
REGISTRATION PROCEDURES 
4.1 
Investigator and research associate registration with CTEP 
4.1.1 
CTEP registration procedures 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) policy 
require all investigators participating in any NCI-sponsored clinical trial to register and to renew 
their registration annually. Registration requires the submission of: 
• a completed Statement of Investigator Form (FDA Form 1572) with an original 
signature 
• a current Curriculum Vitae (CV) 
• a completed and signed Supplemental Investigator Data Form (IDF) 
• a completed Financial Disclosure Form (FDF) with an original signature 
Fillable PDF forms and additional information can be found on the CTEP website at 
http://ctep.cancer.gov/investigatorResources/investigator registration.htm. 
For questions about Investigator Registration, please contact the CTEP Investigator Registration 
Help Desk by email at pmbregpend@ctep.nci.nih.gov. 
4.1.2 
CTEP associate registration procedures/CTEP-IAM account 
The Cancer Therapy Evaluation Program (CTEP) Identity and Access Management (IAM) 
application is a web-based application intended for use by both Investigators (i.e., all physicians 
involved in the conduct of NCI-sponsored clinical trials) and Associates (i.e., all staff involved in 
the conduct of NCI-sponsored clinical trials). 
Associates will use the CTEP-IAM application to register (both initial registration and annual re-
registration) with CTEP and to obtain a user account. 
Investigators will use the CTEP-IAM application to obtain a user account only. (See CTEP 
Investigator Registration Procedures above for information on registering with CTEP as an 
Investigator, which must be completed before a CTEP-IAM account can be requested.) 
An active CTEP-IAM user account is required to access all CTEP applications and, if applicable 
(e.g., all Network trials), all Cancer Trials Support Unit (CTSU) applications and websites. 
Additional information can be found on the CTEP website at 
http://ctep.cancer.gov/branches/pmb/associate_registration.htm. 
For questions about Associate Registration or CTEP-IAM Account Creation, please contact the 
CTEP Associate Registration Help Desk by email at ctepreghelp@ctep.nci.nih.gov. 
4.2 
Site registration 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
Each investigator or group of investigators at a clinical site must obtain IRB approval for this 
protocol and submit IRB approval and supporting documentation to the CTSU Regulatory Office 
before they can be approved to enroll patients. Assignment of site registration status in the CTSU 
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Regulatory Support System (RSS) uses extensive data to make a determination of whether a site 
has fulfilled all regulatory criteria including but not limited to: an active Federal Wide Assurance 
(FWA) number, an active roster affiliation with the Lead Network or a participating 
organization, a valid IRB approval, and compliance with all protocol specific requirements. 
Sites participating on the NCI CIRB initiative that are approved by the CIRB for this study are 
not required to submit separate IRB approval documentation to the CTSU Regulatory Office. For 
sites using the CIRB, IRB approval information is received from the CIRB and applied to RSS in 
an automated process. Signatory Institutions must submit a Study Specific Worksheet for Local 
Context (SSW) to the CIRB via IRBManager to indicate their intention to open the study locally. 
The CIRB’s approval of the SSW is then communicated to the CTSU Regulatory Office.  In 
order for the SSW approval to be processed, the Signatory Institution must inform the CTSU 
which CIRB-approved institutions aligned with the Signatory Institution are participating in the 
study. 
4.2.1 
Downloading regulatory documents 
Site registration forms may be downloaded from the NCI Protocol #10013 protocol page located 
on the CTSU Web site. Permission to view and download this protocol is restricted and is based 
on person and site roster data housed in the CTSU RSS. To participate, Investigators and 
Associates must be associated with the Corresponding or Participating protocol organization in 
the RSS.  
• Go to https://www.ctsu.org and log in using your CTEP-IAM username and 
password. 
• Click on the Protocols tab in the upper left of your screen.  
• Either enter the protocol # in the search field at the top of the protocol tree, or 
• Click on the By Lead Organization folder to expand, then select LAO-NC010 and 
protocol #10013. 
• Click on LPO Documents, select the Site Registration documents link, and download 
and complete the forms provided. (Note: For sites under the CIRB initiative, IRB data 
will load to RSS as described above.) 
4.2.2 
Requirements For NCI Protocol 10013 site registration: 
• CTSU Transmittal Sheet (optional) 
• IRB approval (for sites not participating via the NCI CIRB; local IRB documentation, 
an IRB-signed CTSU IRB Certification Form, Protocol of Human Subjects Assurance 
Identification/IRB Certification/Declaration of Exemption Form, or combination is 
accepted) 
• Study Chair Approval 
4.2.3 
Submitting regulatory documents 
Submit required forms and documents to the CTSU Regulatory Office, where they will be 
entered and tracked in the CTSU RSS. 
Regulatory Submission Portal: www.ctsu.org (members’ area)  Regulatory Tab  
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Regulatory Submission 
When applicable, original documents should be mailed to: 
CTSU Regulatory Office 
1818 Market Street, Suite 1100 
Philadelphia, PA 19103 
Institutions with patients waiting that are unable to use the Portal should alert the CTSU 
Regulatory Office immediately at 1-866-651-2878 in order to receive further instruction and 
support. 
4.2.4 
Checking site registration status 
You can verify your site registration status on the members’ section of the CTSU website. 
• Go to https://www.ctsu.org and log in to the members’ area using your CTEP-IAM 
username and password. 
• Click on the Regulatory tab at the top of your screen. 
• Click on the Site Registration subtab. 
• Enter your 5-character CTEP Institution Code and click on Go. 
Note: The status given only reflects compliance with IRB documentation and institutional 
compliance with protocol-specific requirements as outlined by the Lead Network. It does not 
reflect compliance with protocol requirements for individuals participating on the protocol or the 
enrolling investigator’s status with the NCI or their affiliated networks. 
4.3 
Patient registration 
4.3.1 
OPEN/IWRS 
Patient enrollment will be facilitated using the Oncology Patient Enrollment Network (OPEN). 
OPEN is a web-based registration system available to users on a 24/7 basis. It is integrated with 
the CTSU Enterprise System for regulatory and roster data interchange and with the Theradex 
Interactive Web Response System (IWRS) for retrieval of patient registration/randomization 
assignment. Patient enrollment data entered by Registrars in OPEN / IWRS will automatically 
transfer to the NCI’s clinical data management system, Medidata Rave. 
The OPEN system will provide the site with a printable confirmation of registration and 
treatment information. Please print this confirmation for your records.  
4.3.2 
OPEN/IWRS user requirements 
OPEN/IWRS users must meet the following requirements: 
• Have a valid CTEP-IAM account (i.e., CTEP username and password). 
• To enroll patients: Be on an ETCTN Corresponding or Participating Organization 
roster with the role of Registrar. 
• Have regulatory approval for the conduct of the study at their site. 
Prior to accessing OPEN/IWRS, site staff should verify the following: 
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• All eligibility criteria have been met within the protocol stated timeframes.  
• If applicable, all patients have signed an appropriate consent form and HIPAA 
authorization form. 
4.3.3 
Patient Enrollment Instructions  
N/A 
4.3.4 
OPEN/IWRS Questions? 
Further instructional information on OPEN is provided on the OPEN tab of the CTSU website at 
https://www.ctsu.org or at https://open.ctsu.org. For any additional questions contact the CTSU 
Help Desk at 1-888-823-5923 or ctsucontact@westat.com.  
4.4 
Patient Randomization 
Patients will be randomized in a 1:2 ratio between Arm A (chemotherapy alone, n = 20) and Arm 
B (chemotherapy plus atezolizumab, n = 40) and will be stratified by clinical stage (stage II vs. 
stage III). The randomization table will be generated using the SAS program PROC PLAN. 
Enrollment will continue until 60 evaluable or 72 total patients are enrolled, whichever comes 
first. Enrollment of up to 72 patients is to account for up to 20% of patients being non-evaluable 
for primary endpoint(s).  Randomization will occur with OPEN registration. 
4.5 
General guidelines 
Following registration, patients should begin protocol treatment within 14 days. Issues that 
would cause treatment delays should be discussed with the Principal Investigator. If a patient 
does not receive protocol therapy following registration, the patient’s registration on the study 
may be canceled. The Study Coordinator should be notified of cancellations as soon as possible. 
 
 
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tolerated without infusion-associated AEs, the second infusion may be delivered over 30 (± 10) 
minutes. If the 30-minute infusion is well tolerated, all subsequent infusions may be delivered 
over 30 (± 10) minutes. For the first infusion, the patient’s vital signs (heart rate, respiratory rate, 
blood pressure, and temperature) should be determined within 60 minutes before, during (every 
15 [± 5] minutes), and 30 (± 10) minutes after the infusion. For subsequent infusions, vital signs 
will be collected within 60 minutes before and within 30 minutes after the infusion. Vital signs 
should be collected during the infusion only if clinically indicated. Patients will be informed 
about the possibility of delayed post-infusion symptoms and instructed to contact their study 
physician if they develop such symptoms. 
Premedication is not permitted for the first dose of atezolizumab. Premedication with 
antihistamines or antipyretics/analgesics (e.g. acetaminophen) may be administered for 
subsequent infusions at the discretion of the treating physician. The management of infusion-
related reactions will be according to severity as follows: 
• In the event that a patient experiences a grade 1 infusion-related reaction during 
Cycle 1, the infusion rate should be reduced to half the rate being given at the time of 
event onset. Once the event has resolved, the investigator should wait for 30 minutes 
while delivering the infusion at the reduced rate. If tolerated, the infusion rate may 
then be increased to the original rate. 
• In the event that a patient experiences a grade 2 infusion-related reaction, or flushing, 
fever, or throat pain, the infusion should be immediately interrupted and the patient 
should receive aggressive symptomatic treatment. The infusion should be restarted 
only after the symptoms have adequately resolved to baseline grade. The infusion rate 
at restart should be half of the infusion rate that was in progress at the time of the 
onset of the infusion-related reaction. For subsequent infusions, administer oral 
premedication with antihistamine and anti-pyretic and monitor closely for infusion-
related reactions. 
• For grade 3 or 4 infusion-related reactions, the infusion should be stopped 
immediately, and aggressive resuscitation and supportive measures should be initiated 
(e.g., oral or IV antihistamine, anti-pyretic, glucocorticoids, epinephrine, 
bronchodilators, oxygen). Atezolizumab should be permanently discontinued. 
Resumption of atezolizumab may be considered in patients who are deriving benefit 
and have fully recovered from the immune-related event; retreatment requires 
consultation with, and consent of, the trial Principal Investigator (PI). 
For anaphylaxis precautions, use the following procedure: 
Equipment Needed 
• Tourniquet 
• Oxygen 
• Epinephrine for subcutaneous, intravenous, and/or endotracheal use in accordance 
with standard practice  
• Antihistamines 
• Corticosteroids 
• Intravenous infusion solutions, tubing, catheters, and tape 
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Procedures 
In the event of a suspected anaphylactic reaction during atezolizumab infusion, the following 
procedures should be performed: 
1. Stop the study drug infusion. 
2. Apply a tourniquet proximal to the injection site to slow systemic absorption of 
study drug. Do not obstruct arterial flow in the limb. 
3. Maintain an adequate airway. 
4. Administer antihistamines, epinephrine, or other medications as required by 
patient status and directed by the physician in charge. 
5. Continue to observe the patient and document observation. 
5.1.2 
Paclitaxel 
Note: Contact of the undiluted concentrate with plasticized PVC equipment of devices used to 
prepare solutions for infusion is not recommended. In order to minimize patient exposure to the 
plasticizer DEHP [di-(2-ethylhexyl)phthalate], which may be leached from PVC infusion bags or 
sets, diluted paclitaxel solutions should be stored in bottles (glass, polypropylene) or plastic bags 
(polypropylene, polyolefin) and administered with polyethylene-lined administration sets. 
All patients should be premedicated prior to paclitaxel administration in order to prevent severe 
hypersensitivity reactions. Such premedication should consist of dexamethasone 20 mg PO 
administered approximately 12 and 6 hours before paclitaxel, diphenhydramine (or equivalent) 
50 mg IV 30-60 minutes prior to paclitaxel, and famotidine 20 mg IV 30-60 minutes prior to 
paclitaxel. 
Paclitaxel must be diluted prior to infusion. Paclitaxel should be diluted in 0.9% Sodium 
Chloride Injection, USP, 5% Dextrose Injection, USP, 5% Dextrose and 0.9% Sodium Chloride 
Injection, USP, or 5% Dextrose in Ringer’s Injection to a final concentration of 0.3 to 1.2 
mg/mL. 
Administer paclitaxel IV over one hour through an in-line filter with a microporous membrane 
not greater than 0.22 microns. Use of filter devices such as IVEX-2 filters which incorporate 
short inlet and outlet PVC-coating tubing has not resulted in significant leaching of DEHP. The 
Chemo Dispensing Pin device or similar devices with spikes should not be used with vials of 
paclitaxel since they can cause the stopper to collapse resulting in loss of sterile integrity of the 
paclitaxel solution. 
5.1.3 
Carboplatin 
Note: Aluminum reacts with carboplatin causing precipitate formation and loss of potency, 
therefore, needles or intravenous sets containing aluminum parts that may come in contact with 
the drug must not be used for the preparation or administration of carboplatin. 
All patients should be premedicated prior to carboplatin administration in order to prevent 
emesis.  Such premedication should consist of palonosetron 0.25 mg IV 30-60 minutes prior to 
carboplatin (or other 5HT3 antagonist). 
Carboplatin can be diluted to concentrations as low as 0.5 mg/mL with 5% Dextrose in Water 
(D5W) or 0.9% Sodium Chloride Injection, USP. 
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5.2 
General concomitant medication and supportive care guidelines 
Because there is a potential for interaction of atezolizumab, paclitaxel, and carboplatin with other 
concomitantly administered drugs, the case report form must capture the concurrent use of all 
other drugs, over-the-counter medications, or alternative therapies. The Principal Investigator 
should be alerted if the patient is taking any agent known to affect or with the potential for drug 
interactions. The study team should check a frequently-updated medical reference for a list of 
drugs to avoid or minimize use of. 
5.2.1 
Atezolizumab general concomitant medication guidelines 
Concomitant therapy includes any prescription medications or over the counter preparations used 
by a patient between the 7 days preceding the screening evaluation and the treatment 
discontinuation visit. 
Patients who experience infusion-associated symptoms may be treated symptomatically with 
acetaminophen, ibuprofen, diphenhydramine, and/or cimetidine or another H2 receptor 
antagonist, as per standard practice (for sites outside the United States, equivalent medications 
may be substituted per local practice). Serious infusion associated events manifested by dyspnea, 
hypotension, wheezing, bronchospasm, tachycardia, reduced oxygen saturation, or respiratory 
distress should be managed with supportive therapies as clinically indicated (e.g., supplemental 
oxygen and β2-adrenergic agonists; see Section 5.1.1). 
Systemic corticosteroids and TNFα inhibitors may attenuate potential beneficial immunologic 
effects of treatment with atezolizumab but may be administered at the discretion of the treating 
physician. If feasible, alternatives to corticosteroids should be considered. Premedication may be 
administered for Cycles ≥2 at the discretion of the treating physician. The use of inhaled 
corticosteroids and mineralocorticoids (e.g., fludrocortisone) for patients with orthostatic 
hypotension or adrenocortical insufficiency is allowed. Megestrol administered as appetite 
stimulant is acceptable while the patient is enrolled in the study.  
Patients who use oral contraceptives, hormone-replacement therapy, prophylactic or therapeutic 
anticoagulation therapy (such as low-molecular-weight heparin or warfarin at a stable dose 
level), or other allowed maintenance therapy (see Section 3.2) should continue their use. 
Females of reproductive potential should use highly effective means of contraception. 
5.2.2 
Atezolizumab excluded therapies 
Any concomitant therapy intended for the treatment of cancer, whether health 
authority-approved or experimental, is prohibited. This includes but is not limited to the 
following: 
• Chemotherapy, hormonal therapy, immunotherapy, radiotherapy, investigational 
agents, or herbal therapy (except for maintenance therapies outlined in Section 3.2 
and Section 5.2.1). 
o After Cycle 1, certain forms of radiotherapy may be considered for pain palliation 
if patients are deriving benefit (e.g., treatment of known bony metastases); 
atezolizumab administration may be suspended during radiotherapy. 
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It is strongly recommended that:  
• Traditional herbal medicines not be administered because the ingredients of many 
herbal medicines are not fully studied and their use may result in unanticipated 
drug-drug interactions that may cause, or confound assessment of, toxicity. 
• The use of a RANKL inhibitor (denosumab) be discontinued during the study; this 
agent could potentially alter the activity and the safety of atezolizumab. 
Patients are not allowed to receive immunostimulatory agents, including, but not limited to, IFN-
α, IFN-γ, or IL-2, during the entire study. These agents, in combination with atezolizumab, could 
potentially increase the risk for autoimmune conditions. 
Patients should also not be receiving immunosuppressive medications, including, but not limited 
to, cyclophosphamide, azathioprine, methotrexate, and thalidomide. These agents could 
potentially alter the activity and the safety of atezolizumab. Systemic corticosteroids and anti-
TNFα agents may attenuate potential beneficial immunologic effects of treatment with 
atezolizumab but may be administered at the discretion of the treating physician. If feasible, 
alternatives to these agents should be considered. 
In addition, all patients (including those who discontinue the study early) should not receive 
other immunostimulatory agents for 10 weeks after the last dose of atezolizumab. 
5.2.3 
Paclitaxel general concomitant medication guidelines 
Patients should receive premedications as described in Section 5.1.2. 
The metabolism of paclitaxel is catalyzed by cytochrome P450 enzymes CYP2C8 and CYP3A4. 
Caution should be exercised when administering paclitaxel concomitantly with known substrates 
or inhibitors of the cytochrome P450 isoenzymes CYP2C8 and CYP3A4. Caution should be 
exercised when paclitaxel is concomitantly administered with known substrates (e.g., 
midazolam, buspirone, felodipine, lovastatin, eletriptan, sildenafil, simvastatin, and triazolam), 
inhibitors (e.g., atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, 
nelfinavir, ritonavir, saquinavir, and telithromycin), and inducers (e.g., rifampin and 
carbamazepine) of CYP3A4. 
Caution should also be exercised when paclitaxel is concomitantly administered with known 
substrates (e.g., repaglinide and rosiglitazone), inhibitors (e.g., gemfibrozil), and inducers (e.g., 
rifampin) of CYP2C8. 
5.2.4 
Carboplatin general concomitant medication guidelines 
Carboplatin can induce emesis. The incidence and intensity of emesis have been reduced by 
using premedication with antiemetics. Patients will be premedicated with an antiemetic prior to 
paclitaxel as described in Section 5.1.2, so no additional guidance is provided. 
The renal effects of nephrotoxic compounds may be potentiated by carboplatin. 
5.3 
Surgery 
Standard treatment for curative intent in stages II-III TNBC includes AC. If a patient experiences 
significant toxicity from neoadjuvant chemotherapy, that patient will proceed to surgery and 
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should complete standard chemotherapy if able postoperatively. Surgery should be scheduled to 
take place 3-6 weeks following the last dose of neoadjuvant chemotherapy. A surgical delay 
beyond the timeframe described above requires a discussion with the principal investigator. 
The type of breast surgery (either mastectomy or lumpectomy) is determined by the treating 
surgeon according to the institutional standard, with the goal of completely excising the tumor. A 
negative margin is required unless further excision is not possible. 
The actual surgical/therapeutic approached taken will be recorded as: 
• Partial mastectomy at first attempt (removal of the cancer as well as some of the 
breast tissue around the tumor and the fascia over the chest muscles below the tumor, 
if indicated) 
• Re-excision after partial mastectomy as first attempt 
• Total mastectomy after partial mastectomy as first attempt 
• Modified radical mastectomy (record preservation or removal of pectoralis minor) 
• Radical mastectomy (does not include resection of less than 25% of pectoralis major) 
• Remained inoperable 
• Disease progressed 
• Other 
The type of lymph node surgery will be determined by the treating surgeon according to the 
institutional standard. 
5.4 
Adjuvant Treatment 
Dose-dense AC (ddAC) will be given in the adjuvant setting as per routine care.  ddAC consists 
of doxorubicin at 60 mg/m2 on Day 1 of each 2-week cycle plus cyclophosphamide at 600 mg/m2 
on Day 1 of each 2-week cycle for a total of 4 cycles. 
5.5 
Specimen collection for correlative studies 
The study design presents unique opportunities for tissue acquisition and correlative science in 
the context of neoadjuvant chemotherapy. We will obtain tumor tissue at baseline, following 
initiation of therapy, and at the time of definitive surgery. 
All patients will have research core biopsies of the tumor performed at baseline and after the first 
cycle of therapy (Day 18-22). Tumor tissue will be obtained from all patients at the time of 
surgery. 
Specialized tissue specimen collection/shipment kits will be used for this study. Kits can be 
requested by emailing the Tissue Procurement Core at WUMC at tbank@wustl.edu, referencing 
“Kit request” in the subject line. Provide first and last name, phone number, email, and direct 
shipping address. Reference protocol short title “Neoadj Chemo and Atezolizumab in TNBC” 
and number of kits needed. Limit of 3 kits per request. If more than 3 kits are needed, please 
provide justification. Kits will be distributed within 10 days of request receipt. Each kit contains 
the necessary materials that are needed for the biospecimen (tissue and blood) collection at one 
time point on this trial. 
The required biopsies include two core biopsies in 10% buffered formalin and two core biopsies 
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frozen immediately at bedside in separate OCT blocks to preserve the RNA and DNA of the 
tumor. The first core should be placed in 10% buffered formalin, the second in OCT, the third in 
formalin, and the fourth in OCT. 
5.5.1 
Required pre-treatment core biopsy for biomarker and correlative studies 
• A research biopsy is mandatory for all patients prior to initiating therapy. 
• It is recommended to use the specimen collection/shipping kits provided. 
• The needle used to obtain the core biopsies should be 14 G. 
• It is strongly suggested that core biopsies be image-guided. 
• Tissue may be obtained concurrent with another procedure (clip placement, 
axillary node FNA, port placement) or as a separate procedure. 
• The required biopsies include two core biopsies in 10% buffered formalin and 
two core biopsies frozen immediately at bedside in separate OCT blocks to 
preserve the RNA and DNA of the tumor. 
• It is also permissible to submit samples that were taken prior to study 
enrollment, such as during the diagnostic biopsy procedure as long as: a) the 
additional (un-sectioned) frozen biopsies were prepared in cryomolds and 
OCT at the bedside as described in the kit and held with an accession number 
in a pathology department at -70C or lower until release to the CSB and b): 
the two formalin-fixed biopsies were placed in 10% buffered formalin 
overnight and processed into two separate paraffin blocks. 
5.5.2 
Required on-treatment core biopsy for correlative studies 
• A research biopsy is mandatory for all patients after one cycle of therapy and should 
be obtained on day 18-22. 
• It is recommended to use the specimen collection/shipping kits provided. 
• The needle used to obtain the core biopsies should be 14 G. 
• It is strongly suggested that core biopsies be image-guided. 
• The required biopsies include two core biopsies in 10% buffered formalin and two 
core biopsies frozen immediately at bedside in separate OCT blocks to preserve the 
RNA and DNA of the tumor. 
5.5.3 Required tissue collection at time of surgery for all patients after the completion of 
neoadjuvant chemotherapy for correlative studies 
• Following completion of neoadjuvant chemotherapy, an intra-operative core biopsy 
of residual tumor by the surgeon prior to its resection is required. If no gross residual 
tumor can be identified, then a core biopsy of the tumor bed should be done prior to 
its resection. 
• The required biopsies include: Two core biopsies in 10% buffered formalin and two 
core biopsies frozen immediately at bedside in separate OCT blocks to preserve the 
RNA and DNA of the tumor. 
• Alternatively, but not preferred, the site pathologist can remove the tumor samples 
during the dissection of the surgical specimen (using a 5-mm skin punch biopsy 
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device) as long as the samples are frozen or fixed within 30 minutes of removal from 
the patient. 
5.5.4 
Required peripheral blood collection for PBMC isolation 
• Peripheral blood will be collected from all patients at the time points noted above 
(pre-treatment, on-treatment after one cycle of therapy (Day 18-22), after 3 cycles of 
therapy, and post-treatment at the time of surgery). 
• At each time point, collect six 10mL green-top (sodium heparin) tubes (BD 
Vacutainer, Catalog # 366480). 
Details about specimen processing and shipping are included below in Section 9. 
5.6 
Duration of therapy 
In the absence of treatment delays due to adverse event(s), treatment may continue for 4 cycles 
of paclitaxel + carboplatin (with or without atezolizumab) or until one of the following criteria 
applies: 
• Disease progression; note that subjects can be treated beyond progression if 
pseudoprogression is strongly suspected or confirmed 
• Intercurrent illness that prevents further administration of treatment 
• Unacceptable adverse event(s) 
• Patient decides to withdraw from the study 
• General or specific changes in the patient's condition render the patient unacceptable 
for further treatment in the judgment of the investigator 
5.7 
Duration of follow up 
Patients will be followed for one year after removal from study or until death, whichever occurs 
first. Follow-up will be at 6 months and one year post-surgery. Patients who come off study prior 
to surgery will be followed for 30 days. Patients removed from study for unacceptable adverse 
event(s) will be followed until resolution or stabilization of the adverse event. 
5.8 
Criteria for removal from study 
Patients will be removed from study when any of the criteria listed in Section 5.6 applies. The 
reason for study removal and the date the patient was removed must be documented in the Case 
Report Form. 
 
 
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6. 
DOSING DELAYS/DOSE MODIFICATIONS 
6.1 
Atezolizumab 
6.1.1 
General AE management and dose modification guidelines 
There will be no dose reduction for atezolizumab in this study. 
Patients may temporarily suspend study treatment for up to 42 days (6 weeks) beyond the 
scheduled date of delayed infusion if study drug-related toxicity requiring dose suspension is 
experienced. Treatment with paclitaxel and carboplatin may continue if atezolizumab is 
temporarily suspended. If atezolizumab is held because of AEs for >42 days beyond the 
scheduled date of infusion, the patient will be discontinued from atezolizumab and will be 
followed for safety and efficacy as specified in this protocol. If the AE resolves within 42 days 
and the patient is receiving corticosteroid therapy for the event, atezolizumab may be held for 
longer than 42 days (up to 4 weeks) in order to allow tapering of the steroid dose to ≤ 10 mg oral 
prednisone or equivalent. Treatment with paclitaxel and carboplatin may continue if 
atezolizumab is permanently discontinued. 
Dose interruptions for reasons other than toxicity, such as surgical procedures, may be allowed. 
The acceptable length of interruption will be at the discretion of the study PI in consultation with 
CTEP. 
Atezolizumab must be permanently discontinued if the patient experiences any of the 
following events, regardless of benefit: 
• Grade 4 pneumonitis 
• AST or ALT >5×ULN or total bilirubin >3×ULN  
• Grade 4 diarrhea or colitis 
• Grade 4 hypophysitis 
• Any grade myasthenic syndrome/myasthenia gravis, Guillain-Barré or 
meningoencephalitis 
• Grade 4 ocular inflammatory toxicity 
• Grade 4 pancreatitis or any grade of recurrent pancreatitis 
• Grade 4 rash 
• Any grade myocarditis 
Treatment may, under limited and compelling circumstances, be resumed in patients who have 
recovered from the following events, but only after consultation with the trial Principal 
Investigator: 
• Grade 3 pneumonitis 
• Grade 3 ocular inflammatory toxicity 
• Grade 3 or 4 infusion-related reactions 
Any toxicities associated or possibly associated with atezolizumab treatment should be managed 
according to standard medical practice. Additional tests, such as autoimmune serology or 
biopsies, may be used to determine a possible immunogenic etiology. Although most immune-
related adverse events (irAEs) observed with immunomodulatory agents have been mild and 
self-limiting, such events should be recognized early and treated promptly to avoid potential 
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major complications [67]. Discontinuation of atezolizumab may not have an immediate 
therapeutic effect, and there is no available antidote for atezolizumab. In severe cases, immune-
related toxicities may be acutely managed with topical corticosteroids, systemic corticosteroids, 
or other immunosuppressive agents.  The investigator should consider the benefit-risk balance 
prior to further administration of atezolizumab. 
For detailed information regarding management of adverse events associated with atezolizumab, 
please refer to the most current version of the Atezolizumab Investigator’s Brochure and the 
FDA product label. 
The primary approach to grade 1 to 2 irAEs is supportive and symptomatic care with continued 
treatment with atezolizumab; for higher-grade irAEs, atezolizumab should be withheld and oral 
and/or parenteral steroids administered. Recurrent grade 2 irAEs may also mandate withholding 
atezolizumab or the use of steroids. Assessment of the benefit-risk balance should be made by 
the investigator, with consideration of the totality of information as it pertains to the nature of the 
toxicity and the degree of clinical benefit a given patient may be experiencing prior to further 
administration of atezolizumab. Atezolizumab should be permanently discontinued in patients 
with life-threatening irAEs. In all cases, treatment with paclitaxel and carboplatin may continue 
if atezolizumab is temporarily suspended or permanently discontinued as long as the treating 
physician deems the patient a candidate for chemotherapy. 
Patients should be assessed clinically (including review of laboratory values) for toxicity prior to, 
during, and after each infusion. If unmanageable toxicity due to atezolizumab occurs at any time 
during the study, treatment with atezolizumab should be discontinued. 
6.1.2 
Management of specific AEs 
Management of certain AEs of concern, including immune-related pneumonitis, hepatitis, colitis, 
endocrinopathies, pancreatitis, neuropathies, meningoencephalitis, and potential ocular toxicities 
are presented in the Atezolizumab Investigator’s Brochure. See Section 5.1.1 for guidelines for 
the management of infusion-related reactions and anaphylaxis. 
Atezolizumab has been associated with risks such as the following:  IRRs and immune−related 
hepatitis, pneumonitis, colitis, pancreatitis, diabetes mellitus, hypothyroidism, hyperthyroidism, 
adrenal insufficiency, hypophysitis, Guillain-Barré syndrome, myasthenic syndrome or 
myasthenia gravis, meningoencephalitis, myocarditis, nephritis, myositis, and severe cutaneous 
adverse reactions.  Immune-mediated reactions may involve any organ system and may lead to 
hemophagocytic lymphohistiocytosis and macrophage activation syndrome. 
Pulmonary events 
Dyspnea, cough, fatigue, hypoxia, pneumonitis, and pulmonary infiltrates have been associated 
with the administration of atezolizumab.  Patients will be assessed for pulmonary signs and 
symptoms throughout the study. 
All pulmonary events should be thoroughly evaluated for other commonly reported etiologies 
such as pneumonia or other infection, lymphangitic carcinomatosis, pulmonary embolism, heart 
failure, chronic obstructive pulmonary disease, or pulmonary hypertension.  Management 
guidelines for pulmonary events are provided in the table below. 
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Event 
Management 
Pulmonary event, 
Grade 1  
● Continue atezolizumab and monitor closely. 
● Re-evaluate on serial imaging. 
● Consider patient referral to pulmonary specialist. 
Pulmonary event, 
Grade 2 
● Withhold atezolizumab for up to 12 weeks after event onset. a 
● Refer patient to pulmonary and infectious disease specialists and 
consider bronchoscopy or BAL. 
● Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day oral 
prednisone. 
● If event resolves to Grade 1 or better, resume atezolizumab. b 
● If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
● For recurrent events, treat as a Grade 3 or 4 event. 
Pulmonary event, 
Grade 3 or 4 
● Permanently discontinue atezolizumab.  
● Bronchoscopy or BAL is recommended. 
● Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day oral 
prednisone. 
● If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
● If event resolves to Grade 1 or better, taper corticosteroids over 
≥1 month. 
BAL  =  bronchoscopic alveolar lavage 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time will be 
determined by the investigator and the Medical Monitor. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed. 
 
Hepatic events 
Immune-mediated hepatitis has been associated with the administration of atezolizumab.  
Eligible patients must have adequate liver function, as manifested by measurements of total 
bilirubin and hepatic transaminases, and liver function will be monitored throughout study 
treatment.  Management guidelines for hepatic events are provided in the table below. 
Patients with right upper-quadrant abdominal pain and/or unexplained nausea or vomiting should 
have liver function tests (LFTs) performed immediately and reviewed before administration of 
the next dose of study drug. 
For patients with elevated LFTs, concurrent medication, viral hepatitis, and toxic or neoplastic 
etiologies should be considered and addresses, as appropriate. 
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Event 
Management 
Hepatic event, 
Grade 1 
• Continue atezolizumab. 
• Monitor LFTs until values resolve to within normal limits or to 
baseline values.  
Hepatic event, 
Grade 2 
All events: 
• Monitor LFTs more frequently until return to baseline values.  
Events of >5 days’ duration: 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day 
oral prednisone. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Hepatic event, 
Grade 3 or 4 
• Permanently discontinue atezolizumab. 
• Consider patient referral to gastrointestinal specialist for evaluation 
and liver biopsy to establish etiology of hepatic injury.  
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day 
oral prednisone. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, taper corticosteroids over ≥1 
month. 
LFT  =  liver function test. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time will be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
Gastrointestinal events 
Immune-mediated colitis has been associated with the administration of atezolizumab.  
Management guidelines for diarrhea or colitis are provided in the table below.   
All events of diarrhea or colitis should be thoroughly evaluated for other more common 
etiologies.  For events of significant duration or magnitude or associated with signs of systemic 
inflammation or acute-phase reactants (e.g., increased C-reactive protein, platelet count, or 
bandemia):  Perform sigmoidoscopy (or colonoscopy, if appropriate) with colonic biopsy, with 
three to five specimens for standard paraffin block to check for inflammation and lymphocytic 
infiltrates to confirm colitis diagnosis. 
Event 
Management 
Diarrhea or 
colitis, Grade 1 
• Continue atezolizumab. 
• Initiate symptomatic treatment. 
• Endoscopy is recommended if symptoms persist for >7 days. 
• Monitor closely. 
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Event 
Management 
Diarrhea or 
colitis, Grade 2 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Initiate symptomatic treatment. 
• Patient referral to GI specialist is recommended. 
• For recurrent events or events that persist  >5 days, initiate treatment 
with corticosteroids equivalent to 1−2 mg/kg/day oral prednisone.  
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Diarrhea or 
colitis, Grade 3 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Refer patient to GI specialist for evaluation and confirmatory biopsy. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day IV 
methylprednisolone and convert to 1−2 mg/kg/day oral prednisone or 
equivalent upon improvement. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Diarrhea or 
colitis, Grade 4 
• Permanently discontinue atezolizumab. 
• Refer patient to GI specialist for evaluation and confirmation biopsy. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day IV 
methylprednisolone and convert to 1−2 mg/kg/day oral prednisone or 
equivalent upon improvement. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, taper corticosteroids over 
≥1 month. 
GI = gastrointestinal. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
Endocrine disorders 
Thyroid disorders, adrenal insufficiency, diabetes mellitus, and pituitary disorders have been 
associated with the administration of atezolizumab.  Management guidelines for endocrine 
events are provided in the table below. 
Patients experiencing one or more unexplained AEs possibly indicative of endocrine dysfunction 
(including headache, fatigue, myalgias, impotence, mental status changes, and constipation) 
should be investigated for the presence of thyroid, pituitary, or adrenal endocrinopathies. The 
patient should be referred to an endocrinologist if an endocrinopathy is suspected. 
Thyroid-stimulating hormone (TSH) and free T3 and T4 levels should be obtained to determine 
whether thyroid abnormalities are present. Pituitary hormone levels and function tests [e.g., TSH, 
growth hormone, luteinizing hormone, follicle stimulating hormone, testosterone, prolactin, 
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adrenocorticotropic hormone (ACTH) levels, and ACTH stimulation test] and MRI of the brain 
(with detailed pituitary sections) may help to differentiate primary pituitary insufficiency from 
primary adrenal insufficiency. The table below describes dose management guidelines for 
hyperthyroidism, hypothyroidism, symptomatic adrenal insufficiency, and hyperglycemia. 
Event 
Management 
Asymptomatic 
hypothyroidism 
• Continue atezolizumab. 
• Initiate treatment with thyroid replacement hormone. 
• Monitor TSH weekly. 
Symptomatic 
hypothyroidism 
• Withhold atezolizumab. 
• Initiate treatment with thyroid replacement hormone. 
• Monitor TSH weekly. 
• Consider patient referral to endocrinologist. 
• Resume atezolizumab when symptoms are controlled and 
thyroid function is improving. 
Asymptomatic 
hyperthyroidism 
TSH ≥0.1 mU/L and <0.5 mU/L: 
• Continue atezolizumab. 
• Monitor TSH every 4 weeks. 
TSH <0.1 mU/L: 
• Follow guidelines for symptomatic hyperthyroidism. 
Symptomatic 
hyperthyroidism 
• Withhold atezolizumab. 
• Initiate treatment with anti-thyroid drug such as methimazole or 
carbimazole as needed. 
• Consider patient referral to endocrinologist. 
• Resume atezolizumab when symptoms are controlled and 
thyroid function is improving. 
• Permanently discontinue atezolizumab.  
Symptomatic adrenal 
insufficiency, Grade 2−4  
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Refer patient to endocrinologist. 
• Perform appropriate imaging. 
• Initiate treatment with corticosteroids equivalent to 
1−2 mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon 
improvement. 
• If event resolves to Grade 1 or better and patient is stable on 
replacement therapy, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better or patient is not 
stable on replacement therapy while withholding atezolizumab, 
permanently discontinue atezolizumab.  
Hyperglycemia, Grade 1 
or 2  
• Continue atezolizumab. 
• Investigate for diabetes.  If patient has Type 1 diabetes, treat as a 
Grade 3 event.  If patient does not have Type 1 diabetes, treat as 
per institutional guidelines. 
• Monitor for glucose control. 
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Event 
Management 
Hyperglycemia, Grade 3 
or 4 
• Withhold atezolizumab. 
• Initiate treatment with insulin. 
• Monitor for glucose control. 
• Resume atezolizumab when symptoms resolve and glucose 
levels are stable. 
Hypophysitis (pan-
hypopituitarism), Grade 
2 or 3  
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Refer patient to endocrinologist. 
• Perform brain MRI (pituitary protocol). 
• Initiate treatment with corticosteroids equivalent to 
1−2 mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon 
improvement. 
• Initiate hormone replacement if clinically indicated. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab.  
• For recurrent hypophysitis, treat as a Grade 4 event. 
Hypophysitis (pan-
hypopituitarism), Grade 
4  
• Permanently discontinue atezolizumab.  
• Refer patient to endocrinologist. 
• Perform brain MRI (pituitary protocol). 
• Initiate treatment with corticosteroids equivalent to 
1−2 mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon 
improvement. 
• Initiate hormone replacement if clinically indicated. 
MRI = magnetic resonance imaging; TSH = thyroid-stimulating hormone. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
Ocular events 
An ophthalmologist should evaluate visual complaints (e.g., uveitis, retinal events). 
Management guidelines for ocular events are provided in the table below. 
Event 
Management 
Ocular event, 
Grade 1  
• Continue atezolizumab. 
• Patient referral to ophthalmologist is strongly recommended. 
• Initiate treatment with topical corticosteroid eye drops and topical 
immunosuppressive therapy. 
• If symptoms persist, treat as a Grade 2 event. 
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Event 
Management 
Ocular event, 
Grade 2 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Patient referral to ophthalmologist is strongly recommended. 
• Initiate treatment with topical corticosteroid eye drops and topical 
immunosuppressive therapy. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Ocular event, 
Grade 3 or 4 
• Permanently discontinue atezolizumab. 
• Refer patient to ophthalmologist. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day 
oral prednisone.   
• If event resolves to Grade 1 or better, taper corticosteroids over 
≥1 month. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
Immune-mediated- Myocarditis 
Immune-mediated myocarditis has been associated with the administration of atezolizumab.  
Immune-mediated myocarditis should be suspected in any patient presenting with signs or 
symptoms suggestive of myocarditis, including, but not limited to, laboratory (e.g., B-NP [B-
Natriuretic Peptide]) or cardiac imaging abnormalities, dyspnea, chest pain, palpitations, fatigue, 
decreased exercise tolerance, or syncope.  
Immune-mediated myocarditis needs to be distinguished from myocarditis resulting from 
infection (commonly viral, e.g., in a patient who reports a recent history of gastrointestinal 
illness), ischemic events, underlying arrhythmias, exacerbation of preexisting cardiac conditions, 
or progression of malignancy.  All patients with possible myocarditis should be urgently 
evaluated by performing cardiac enzyme assessment, an electrocardiogram (ECG), a chest X-ray, 
an echocardiogram, and a cardiac MRI as appropriate per institutional guidelines.  A cardiologist 
should be consulted.  An endomyocardial biopsy may be considered to enable a definitive 
diagnosis and appropriate treatment, if clinically indicated. 
Patients with signs and symptoms of myocarditis, in the absence of an identified alternate 
etiology, should be treated according to the guidelines in the table below. 
Event 
Management 
Immune-related 
myocarditis, Grade 2 
• Withhold atezolizumab for up to 12 weeks after event onset a. 
• Refer patient to cardiologist. 
• Initiate treatment as per institutional guidelines and consider 
antiarrhythmic drugs, temporary pacemaker, ECMO, or VAD as 
appropriate. 
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Event 
Management 
• Consider treatment with corticosteroids equivalent to 
1−2 mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon improvement. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Immune-related 
myocarditis, Grade 3-
4 
• Permanently discontinue atezolizumab. 
• Refer patient to cardiologist. 
• Initiate treatment as per institutional guidelines and consider 
antiarrhythmic drugs, temporary pacemaker, ECMO, or VAD as 
appropriate. 
• Initiate treatment with corticosteroids equivalent to 1−2 
mg/kg/day IV methylprednisolone and convert to 1−2 mg/kg/day 
oral prednisone or equivalent upon improvement. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, taper corticosteroids 
over ≥1 month. 
ECMO = extracorporeal membrane oxygenation; VAD = ventricular assist device. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
documented by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed. 
 
Infusion-Related Reactions and Cytokine-Release Syndrome 
No premedication is indicated for the administration of Cycle 1 of atezolizumab.  However, 
patients who experience an infusion-related reaction (IRR) or cytokine-release syndrome (CRS) 
with atezolizumab may receive premedication with antihistamines, antipyretics, and/or 
analgesics (e.g., acetaminophen) for subsequent infusions.  Metamizole (dipyrone) is prohibited 
in treating atezolizumab-associated IRRs because of its potential for causing agranulocytosis. 
IRRs are known to occur with the administration of monoclonal antibodies and have been 
reported with atezolizumab.  These reactions, which are thought to be due to release of cytokines 
and/or other chemical mediators, occur within 24 hours of atezolizumab administration and are 
generally mild to moderate in severity. 
CRS is defined as a supraphysiologic response following administration of any immune therapy 
that results in activation or engagement of endogenous or infused T cells and/or other immune 
effector cells.  Symptoms can be progressive, always include fever at the onset, and may include 
hypotension, capillary leak (hypoxia), and end-organ dysfunction (Lee et al., 2019).  CRS has 
been well documented with chimeric antigen receptor T-cell therapies and bispecific T-cell 
engager antibody therapies but has also been reported with immunotherapies that target PD-1 or 
PD-L1 (Rotz et al., 2017; Adashek and Feldman 2019) including atezolizumab. 
There may be significant overlap in signs and symptoms of IRRs and CRS, and in recognition of 
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the challenges in clinically distinguishing between the two, consolidated guidelines for medical 
management of IRRs and CRS are provided in the table below. 
Management Guidelines for Infusion-Related Reactions and Cytokine-Release Syndrome 
Event 
Management 
Grade 1a  
Feverb with or 
without 
constitutional 
symptoms 
● Immediately interrupt infusion. 
● Upon symptom resolution, wait 30 minutes and then restart infusion at half the 
rate being given at the time of event onset. 
● If the infusion is tolerated at the reduced rate for 30 minutes, the infusion rate 
may be increased to the original rate. 
● If symptoms recur, discontinue infusion of this dose. 
● Administer symptomatic treatment,c including maintenance of IV fluids for 
hydration. 
● In case of rapid decline or prolonged CRS (> 2 days) or in patients with 
significant symptoms and/or comorbidities, consider managing as per Grade 2. 
● For subsequent infusions, consider administration of oral premedication with 
antihistamines, anti-pyretics, and/or analgesics, and monitor closely for IRRs 
and/or CRS. 
Grade 2a 
Feverb with 
hypotension not 
requiring 
vasopressors 
and/or 
Hypoxia requiring 
low-flow oxygend 
by nasal cannula 
or blow-by 
● Immediately interrupt atezolizumab infusion. 
● Upon symptom resolution, wait for 30 minutes and then restart infusion at half 
the rate being given at the time of event onset. 
● If symptoms recur, discontinue infusion of this dose. 
● Administer symptomatic treatment.c 
● For hypotension, administer IV fluid bolus as needed. 
● Monitor cardiopulmonary and other organ function closely (in the ICU, if 
appropriate).  Administer IV fluids as clinically indicated and manage 
constitutional symptoms and organ toxicities as per institutional practice. 
● Rule out other inflammatory conditions that can mimic CRS (e.g., sepsis).  If no 
improvement within 24 hours, initiate workup and assess for signs and 
symptoms of HLH or MAS. 
● Consider IV corticosteroids (e.g., methylprednisolone 2 mg/kg/day or 
dexamethasone 10 mg every 6 hours). 
● Consider anti-cytokine therapy.e 
● Consider hospitalization until complete resolution of symptoms. If no 
improvement within 24 hours, manage as per Grade 3, that is, hospitalize patient 
(monitoring in the ICU is recommended), permanently discontinue 
atezolizumab. 
● If symptoms resolve to Grade 1 or better for 3 consecutive days, the next dose of 
atezolizumab may be administered.  For subsequent infusions, consider 
administration of oral premedication with antihistamines, anti-pyretics, and/or 
analgesics and monitor closely for IRRs and/or CRS. 
● If symptoms do not resolve to Grade 1 or better for 3 consecutive days, contact 
the sponsor-investigator. 
Grade 3a 
Feverb with 
hypotension 
requiring a 
vasopressor (with 
or without 
● Permanently discontinue atezolizumab.f 
● Administer symptomatic treatment.c 
● For hypotension, administer IV fluid bolus and vasopressor as needed. 
● Monitor cardiopulmonary and other organ function closely; monitoring in the 
ICU is recommended.  Administer IV fluids as clinically indicated and manage 
constitutional symptoms and organ toxicities as per institutional practice. 
● Rule out other inflammatory conditions that can mimic CRS (e.g., sepsis).  If no 
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vasopressin)  
and/or 
Hypoxia requiring 
high-flow 
oxygend 
by nasal cannula, 
face mask, non-
rebreather mask, 
or venturi mask 
improvement within 24 hours, initiate workup and assess for signs and 
symptoms of HLH or MAS. 
● Administer IV corticosteroids (e.g., methylprednisolone 2 mg/kg/day or 
dexamethasone 10 mg every 6 hours). 
● Consider anti-cytokine therapy.e 
● Hospitalize patient until complete resolution of symptoms.  If no improvement 
within 24 hours, manage as per Grade 4, that is, admit patient to ICU and initiate 
hemodynamic monitoring, mechanical ventilation, and/or IV fluids and 
vasopressors as needed; for patients who are refractory to anti-cytokine therapy, 
experimental treatments may be considered at the discretion of the investigator. 
Grade 4a 
Feverb with 
hypotension 
requiring multiple 
vasopressors 
(excluding 
vasopressin) 
and/or 
Hypoxia requiring 
oxygen by 
positive pressure 
(e.g., CPAP, 
BiPAP, intubation 
and mechanical 
ventilation) 
● Permanently discontinue atezolizumab.f 
● Administer symptomatic treatment.c 
● Admit patient to ICU and initiate hemodynamic monitoring, mechanical 
ventilation, and/or IV fluids and vasopressors as needed.  Monitor other organ 
function closely.  Manage constitutional symptoms and organ toxicities as per 
institutional practice. 
● Rule out other inflammatory conditions that can mimic CRS (e.g., sepsis).  If no 
improvement within 24 hours, initiate workup and assess for signs and 
symptoms of HLH or MAS. 
● Administer IV corticosteroids (e.g., methylprednisolone 2 mg/kg/day or 
dexamethasone 10 mg every 6 hours). 
● Consider anti-cytokine therapy.e  For patients who are refractory to anti-cytokine 
therapy, experimental treatmentsg may be considered at the discretion of the 
investigator. 
●  Hospitalize patient until complete resolution of symptoms. 
ASTCT= American Society for Transplantation and Cellular Therapy; BiPAP= bi-level positive airway 
pressure; CAR= chimeric antigen receptor; CPAP= continuous positive airway pressure; 
CRS= cytokine-release syndrome; HLH= hemophagocytic lymphohistiocytosis; IRR = infusion-related 
reaction; MAS= macrophage activation syndrome. 
Note: The management guidelines have been adapted from NCCN guidelines for management of 
CAR T-cell-related toxicities (Version 2.2019). 
a. Grading system for management guidelines is based on ASTCT consensus grading for CRS.  NCI 
CTCAE (version as specified in the protocol) should be used when reporting severity of IRRs, CRS, 
or organ toxicities associated with CRS on the Adverse Event eCRF. Organ toxicities associated 
with CRS should not influence overall CRS grading.  
b. Fever is defined as temperature ≥38°C not attributable to any other cause. In patients who develop 
CRS and then receive anti-pyretic, anti-cytokine, or corticosteroid therapy, fever is no longer 
required when subsequently determining event severity (grade).  In this case, the grade is driven by 
the presence of hypotension and/or hypoxia. 
c. Symptomatic treatment may include oral or IV antihistamines, anti-pyretics, analgesics, 
bronchodilators, and/or oxygen.  For bronchospasm, urticaria, or dyspnea, additional treatment may 
be administered as per institutional practice. 
d. Low flow is defined as oxygen delivered at ≤6 L/min, and high flow is defined as oxygen delivered 
at >6 L/min. 
e. There are case reports where anti-cytokine therapy has been used for treatment of CRS with immune 
checkpoint inhibitors (Rotz et al. 2017; Adashek and Feldman 2019), but data are limited, and the 
role of such treatment in the setting of antibody-associated CRS has not been established. 
f. Resumption of atezolizumab may be considered in patients who are deriving benefit and have fully 
recovered from the immune-related event.  Patients can be re-challenged with atezolizumab 
according to institutional guidelines and the above table.  For subsequent infusions, administer oral 
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premedication with antihistamines, anti-pyretics, and/or analgesics, and monitor closely for IRRs 
and/or CRS.  Premedication with corticosteroids and extending the infusion time may also be 
considered after considering the benefit-risk ratio. 
g. Refer to Riegler et al. for information on experimental treatments for CRS. 
 
Pancreatic events 
Symptoms of abdominal pain associated with elevations of amylase and lipase, suggestive of 
pancreatitis, have been associated with the administration of atezolizumab.  The differential 
diagnosis of acute abdominal pain should include pancreatitis.  Appropriate workup should 
include an evaluation for ductal obstruction, as well as serum amylase and lipase tests.  
Management guidelines for pancreatic events, including pancreatitis, are provided in the table 
below. 
Event 
Management 
Amylase and/or lipase 
elevation, Grade 2 
Amylase and/or lipase >1.5−2.0 × ULN: 
• Continue atezolizumab. 
• Monitor amylase and lipase weekly. 
• For prolonged elevation (e.g., >3 weeks), consider treatment 
with corticosteroids equivalent to 10 mg/day oral prednisone. 
Asymptomatic with amylase and/or lipase >2.0−5.0 × ULN: 
• Treat as a Grade 3 event. 
Amylase and/or lipase 
elevation, Grade 3 or 4 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Refer patient to GI specialist. 
• Monitor amylase and lipase every other day. 
• If no improvement, consider treatment with corticosteroids 
equivalent to 1−2 mg/kg/day oral prednisone. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while 
withholding atezolizumab, permanently discontinue 
atezolizumab. c 
• For recurrent events, permanently discontinue atezolizumab. 
Immune-related 
pancreatitis, Grade 2 or 3 
 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Refer patient to GI specialist. 
• Initiate treatment with corticosteroids equivalent to 
1−2 mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon 
improvement. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while 
withholding atezolizumab, permanently discontinue 
atezolizumab.  
• For recurrent events, permanently discontinue atezolizumab. 
Immune-related 
pancreatitis, Grade 4 
• Permanently discontinue atezolizumab. 
• Refer patient to GI specialist. 
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Event 
Management 
• Initiate treatment with corticosteroids equivalent to 
1−2 mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon 
improvement. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive 
agent. 
• If event resolves to Grade 1 or better, taper corticosteroids 
over ≥1 month. 
GI = gastrointestinal. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
Dermatologic events 
Treatment-emergent rash has been associated with atezolizumab.  The majority of cases of rash 
were mild in severity and self-limited, with or without pruritus.  A dermatologist should evaluate 
persistent and/or severe rash or pruritus.  A biopsy should be considered unless contraindicated.  
Management guidelines for dermatologic events are provided in the table below. 
Event 
Management 
Dermatologic 
event, Grade 1  
● Continue atezolizumab. 
● Consider treatment with topical corticosteroids and/or other 
symptomatic therapy (e.g., antihistamines). 
Dermatologic 
event, Grade 2  
● Continue atezolizumab. 
● Consider patient referral to dermatologist. 
● Initiate treatment with topical corticosteroids. 
● Consider treatment with higher-potency topical corticosteroids if event 
does not improve. 
Dermatologic 
event, Grade 3  
● Withhold atezolizumab for up to 12 weeks after event onset. a 
● Refer patient to dermatologist. 
● Initiate treatment with corticosteroids equivalent to 10 mg/day oral 
prednisone, increasing dose to 1-2 mg/kg/day if event does not 
improve within 48-72 hours. 
● If event resolves to Grade 1 or better, resume atezolizumab. b 
● If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab.  
Dermatologic 
event, Grade 4 
● Permanently discontinue atezolizumab.  
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Event 
Management 
Stevens-Johnson 
syndrome or toxic 
epidermal 
necrolysis (any 
grade) 
Additional guidance for Stevens-Johnson syndrome or toxic 
epidermal necrolysis: 
• Withhold atezolizumab for suspected Stevens-Johnson syndrome or 
toxic epidermal necrolysis. 
• Confirm diagnosis by referring patient to a specialist (dermatologist, 
ophthalmologist, or urologist as relevant) for evaluation and, if 
indicated, biopsy. 
• Follow the applicable treatment and management guidelines above. 
● If Stevens-Johnson syndrome or toxic epidermal necrolysis is 
confirmed, permanently discontinue atezolizumab. 
Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event onset) to 
allow for corticosteroids (if initiated) to be reduced to the equivalent of ≤10 mg/day oral 
prednisone.  The acceptable length of the extended period of time must be determined by the 
investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent of 
≤10 mg/day oral prednisone before atezolizumab can be resumed. 
 
Neurologic disorders 
Myasthenia gravis and Guillain-Barré syndrome have been observed with single agent 
atezolizumab.  Patients may present with signs and symptoms of sensory and/or motor 
neuropathy.  Diagnostic work-up is essential for an accurate characterization to differentiate 
between alternative etiologies. 
Event 
Management 
Immune-related 
neuropathy, Grade 
1 
• Continue atezolizumab. 
• Investigate etiology. 
Immune-related 
neuropathy, Grade 
2  
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Investigate etiology. 
• Initiate treatment as per institutional guidelines. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Immune-related 
neuropathy, Grade 
3 or 4 
• Permanently discontinue atezolizumab.  
• Initiate treatment as per institutional guidelines. 
Myasthenia gravis 
and Guillain-Barré 
syndrome (any 
grade) 
• Permanently discontinue atezolizumab. 
• Refer patient to neurologist. 
• Initiate treatment as per institutional guidelines. 
• Consider initiation of corticosteroids equivalent to 1−2 mg/kg/day oral 
or IV prednisone. 
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a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
Immune-Mediated Meningoencephalitis 
Immune-related meningoencephalitis is an identified risk associated with the administration of 
atezolizumab.  Immune-related meningoencephalitis should be suspected in any patient 
presenting with signs or symptoms suggestive of meningitis or encephalitis, including, but not 
limited to, headache, neck pain, confusion, seizure, motor or sensory dysfunction, and altered or 
depressed level of consciousness.  Encephalopathy from metabolic or electrolyte imbalances 
needs to be distinguished from potential meningoencephalitis resulting from infection (bacterial, 
viral, or fungal) or progression of malignancy, or secondary to a paraneoplastic process. 
All patients being considered for meningoencephalitis should be urgently evaluated with a CT 
scan and/or MRI scan of the brain to evaluate for metastasis, inflammation, or edema.  If deemed 
safe by the treating physician, a lumbar puncture should be performed and a neurologist should 
be consulted. 
Patients with signs and symptoms of meningoencephalitis, in the absence of an identified 
alternate etiology, should be treated according to the guidelines. 
Event 
Management 
Immune-related 
meningoencephalitis, 
all grades 
• Permanently discontinue atezolizumab. 
• Refer patient to neurologist. 
• Initiate treatment with corticosteroids equivalent to 1−2 
mg/kg/day IV methylprednisolone and convert to 
1−2 mg/kg/day oral prednisone or equivalent upon 
improvement. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, taper corticosteroids over 
≥1 month. 
 
Renal events 
Immune-mediated nephritis has been associated with the administration of atezolizumab.  
Eligible patients must have adequate renal function.  Renal function, including serum creatinine, 
should be monitored throughout study treatment.  Patients with abnormal renal function should 
be evaluated and treated for other more common etiologies (including prerenal and postrenal 
causes, and concomitant medications such as non-steroidal anti-inflammatory drugs).  Refer the 
patient to a renal specialist if clinically indicated.  A renal biopsy may be required to enable a 
definitive diagnosis and appropriate treatment. 
Patients with signs and symptoms of nephritis, in the absence of an identified alternate etiology, 
should be treated according to the guidelines in the table below. 
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Event 
Management 
Renal event, 
Grade 1 
• Continue atezolizumab. 
• Monitor kidney function, including creatinine, closely until values 
resolve to within normal limits or to baseline values.  
Renal event, 
Grade 2 
• Withhold atezolizumab for up to 12 weeks after event onset. a 
• Refer patient to renal specialist. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day 
oral prednisone. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab. 
Renal event, 
Grade 3 or 4 
• Permanently discontinue atezolizumab. 
• Refer patient to renal specialist and consider renal biopsy. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day 
oral prednisone. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, taper corticosteroids over ≥1 
month. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
determined by the investigator. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed. 
 
Immune-Mediated Myositis 
Immune-mediated myositis has been associated with the administration of atezolizumab.  
Myositis or inflammatory myopathies are a group of disorders sharing the common feature of 
inflammatory muscle injury; dermatomyositis and polymyositis are among the most common 
disorders.  Initial diagnosis is based on clinical (muscle weakness, muscle pain, skin rash in 
dermatomyositis), biochemical (serum creatine kinase increase), and imaging 
(electromyography/MRI) features, and is confirmed with a muscle biopsy. 
Patients with signs and symptoms of myositis, in the absence of an identified alternate etiology, 
should be treated according to the guidelines in table below. 
Event 
Management 
Immune-mediated 
myositis, Grade 1 
• Continue atezolizumab. 
• Refer patient to rheumatologist or neurologist.  
• Initiate treatment as per institutional guidelines. 
Immune-mediated 
myositis, Grade 2 
• Withhold atezolizumab for up to 12 weeks after event onset a and 
contact Medical Monitor. 
• Refer patient to rheumatologist or neurologist. 
• Initiate treatment as per institutional guidelines. 
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Event 
Management 
• Consider treatment with corticosteroids equivalent to 1−2 mg/kg/day 
IV methylprednisolone and convert to 1−2 mg/kg/day oral prednisone 
or equivalent upon improvement. 
• If corticosteroids are initiated and event does not improve within 48 
hours after initiating corticosteroids, consider adding an 
immunosuppressive agent. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab and contact 
Medical Monitor. 
Immune-mediated 
myositis, Grade 3 
• Withhold atezolizumab for up to 12 weeks after event onset a and 
contact Medical Monitor. 
• Refer patient to rheumatologist or neurologist. 
• Initiate treatment as per institutional guidelines.   
• Respiratory support may be required in more severe cases. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day IV 
methylprednisolone, or higher-dose bolus if patient is severely 
compromised (e.g., cardiac or respiratory symptoms, dysphagia, or 
weakness that severely limits mobility); convert to 1−2 mg/kg/day 
oral prednisone or equivalent upon improvement. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, resume atezolizumab. b 
• If event does not resolve to Grade 1 or better while withholding 
atezolizumab, permanently discontinue atezolizumab and contact 
Medical Monitor.  
• For recurrent events, treat as a Grade 4 event. 
Immune-mediated 
myositis, Grade 4 
• Permanently discontinue atezolizumab and contact Medical Monitor. 
• Refer patient to rheumatologist or neurologist. 
• Initiate treatment as per institutional guidelines. 
• Respiratory support may be required in more severe cases. 
• Initiate treatment with corticosteroids equivalent to 1−2 mg/kg/day IV 
methylprednisolone, or higher-dose bolus if patient is severely 
compromised (e.g., cardiac or respiratory symptoms, dysphagia, or 
weakness that severely limits mobility); convert to 1−2 mg/kg/day 
oral prednisone or equivalent upon improvement. 
• If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
• If event resolves to Grade 1 or better, taper corticosteroids over 
≥1 month. 
a Atezolizumab may be withheld for a longer period of time (i.e., >12 weeks after event 
onset) to allow for corticosteroids (if initiated) to be reduced to the equivalent of 
≤10 mg/day oral prednisone.  The acceptable length of the extended period of time must be 
agreed upon by the investigator and the Medical Monitor. 
b If corticosteroids have been initiated, they must be tapered over ≥1 month to the equivalent 
of ≤10 mg/day oral prednisone before atezolizumab can be resumed.  
 
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Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome 
Immune-mediated reactions may involve any organ system and may lead to hemophagocytic 
lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS). 
Patients with suspected HLH should be diagnosed according to published criteria by McClain 
and Eckstein (2017).  A patient should be classified as having HLH if five of the following eight 
criteria are met: 
• Fever ≥ 38.5°C 
• Splenomegaly 
• Peripheral blood cytopenia consisting of at least two of the following: 
– Hemoglobin < 90 g/L (9 g/dL) (<100 g/L [10 g/dL] for infants < 4 weeks old) 
– Platelet count < 100 × 109/L (100,000/mcL) 
– ANC < 1.0 × 109/L (1000/mcL) 
• Fasting triglycerides >2.992 mmol/L (265 mg/dL) and/or fibrinogen <1.5 g/L (150 
mg/dL) 
• Hemophagocytosis in bone marrow, spleen, lymph node, or liver 
• Low or absent natural killer cell activity 
• Ferritin >500 mg/L (500 ng/mL) 
• Soluble interleukin 2 (IL-2) receptor (soluble CD25) elevated ≥ 2 standard deviations 
above age-adjusted laboratory-specific norms 
Patients with suspected MAS should be diagnosed according to published criteria for systemic 
juvenile idiopathic arthritis by Ravelli et al. (2016).  A febrile patient should be classified as 
having MAS if the following criteria are met: 
• Ferritin >684 mg/L (684 ng/mL) 
• At least two of the following: 
– Platelet count ≤ 181 × 109/L (181,000/mcL) 
– AST ≥48 U/L 
– Triglycerides >1.761 mmol/L (156 mg/dL) 
– Fibrinogen ≤3.6 g/L (360 mg/dL) 
Patients with suspected HLH or MAS should be treated according to the guidelines in below. 
Event 
Management 
Suspected HLH 
or MAS 
● Permanently discontinue atezolizumab and contact Medical 
Monitor. 
● Consider patient referral to hematologist. 
● Initiate supportive care, including intensive care monitoring if 
indicated per institutional guidelines. 
● Consider initiation of IV corticosteroids and/or an 
immunosuppressive agent. 
● If event does not improve within 48 hours after initiating 
corticosteroids, consider adding an immunosuppressive agent. 
● If event resolves to Grade 1 or better, taper corticosteroids over 
≥1 month. 
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Event 
Management 
HLH=  hemophagocytic lymphohistiocytosis; MAS= macrophage activation syndrome. 
 
6.2 
Systemic Chemotherapy 
Atezolizumab will be held when paclitaxel and/or carboplatin are held. If there is a need to 
discontinue chemotherapy (such as severe hypersensitivity reaction), patients should continue to 
surgery. 
Paclitaxel Dose Levels 
Level 
Dose 
Starting Dose 
80 mg/m2 
Dose Level -1 
65 mg/m2 
Dose Level -2 
50 mg/m2 
Dose Level -3 
Discontinue 
Carboplatin Dose Levels 
Level 
Dose 
Starting Dose 
AUC 5 
Dose Level -1 
AUC 4 
Dose Level -2 
AUC 3 
Dose Level -3 
Discontinue 
6.2.1 
General Treatment management for paclitaxel and carboplatin 
Dose modifications must be based on AEs that occurred between treatments AND AEs present 
on the scheduled treatment day.  Dose modifications must be based on the AE requiring the 
greatest modification. Chemotherapy doses that have been reduced may not be escalated.  
Chemotherapy should be held for at least 1 week until any AE requiring dose modification 
returns to ≤ grade 1 unless indicated otherwise below.  If recovery to ≤ grade 1 (or to other level 
specified) has not occurred after 3 weeks of delay, therapy must be discontinued. 
 
 
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Disorders 
(Paresthesias, 
peripheral sensory 
neuropathy) 
next treatment to be delayed 
Grade 1 
Maintain dose 
Grade 2 
Maintain dose (must be 
resolved to ≤ grade 1 on 
the next treatment day) 
Reduce by one dose level (hold paclitaxel 
and carboplatin for persistent grade 2 
neuropathy; when ≤ grade 1, resume 
treatment with dose modification for 
paclitaxel but no dose modification for 
carboplatin.  If grade 2 toxicity persists after 
3 weeks of delay, discontinue all 
chemotherapy) 
Grade 3 
First episode: 
Reduce by one dose 
level (must be resolved 
to ≤ grade 1 on the next 
treatment day) 
Second episode: 
Discontinue paclitaxel 
Discontinue paclitaxel 
Grade 4 
Discontinue paclitaxel 
6.2.3 
Treatment management for paclitaxel-related musculoskeletal pain 
Note: these instructions only apply to patients with musculoskeletal pain not controlled by 
analgesics.  Use of narcotics and NSAIDs is encouraged to maintain the paclitaxel dose if 
possible. 
 
Musculoskeletal and 
Connective Tissue 
Disorders 
(Arthralgia, 
myalgia) 
1-7 days duration 
Persistent for > 7 days OR caused the next 
treatment to be delayed 
Grade 1 
Maintain dose 
 
Grade 2 
Maintain dose 
Maintain dose or reduce by one dose level 
(hold paclitaxel and carboplatin for persistent 
grade 2 musculoskeletal pain; when ≤ grade 1, 
resume treatment with dose modification for 
paclitaxel but no dose modification for 
carboplatin. If grade 2 toxicity persists after 3 
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weeks of delay, discontinue all chemotherapy) 
Grade 3 
First episode: 
Reduce by one dose 
level 
Second episode: 
Discontinue 
paclitaxel 
First episode 
Reduce by one dose level or discontinue (hold 
paclitaxel and carboplatin for persistent grade 
3 musculoskeletal pain; when ≤ grade 1, 
resume treatment with dose modification for 
paclitaxel but no dose modification for 
carboplatin. If grade 3 toxicity persists after 3 
weeks of delay, discontinue all chemotherapy) 
Second episode 
Discontinue paclitaxel 
6.2.4 
Other treatment management instructions 
If a paclitaxel-related hypersensitivity reaction occurs despite premedication, treatment as 
medically indicated will be instituted.  For ≤ grade 3 allergic reaction or grade 3 anaphylaxis, 
continuation of paclitaxel is at the investigator’s discretion.  Following a grade 4 allergic reaction 
or grade 4 anaphylaxis, paclitaxel must be permanently discontinued. 
Carboplatin must be permanently discontinued if a grade 3 or 4 hypersensitivity reaction occurs 
that the investigator attributes to carboplatin. 
Unless otherwise specified, paclitaxel or carboplatin that is held due to toxicity will not resume 
until the toxicity has resolved to ≤ grade 1. 
If carboplatin is held due to toxicity, paclitaxel should be held.  If therapy is held for > 2 weeks 
due to persistent carboplatin toxicity, discontinue carboplatin. 
If carboplatin is discontinued due to toxicity, the remaining paclitaxel doses should be 
administered. 
Paclitaxel and carboplatin must be completed within 18 weeks.  Any of the 12 paclitaxel doses or 
4 carboplatin doses remaining after 18 weeks following the first paclitaxel and carboplatin doses 
should not be administered. 
7. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS  
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The 
following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will 
determine whether the event requires expedited reporting via the CTEP Adverse Event Reporting 
System (CTEP-AERS) in addition to routine reporting. 
7.1 
Comprehensive adverse events and potential risks list (CAEPR) 
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset of AEs, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and 
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BLOOD AND LYMPHATIC SYSTEM DISORDERS - Blood and lymphatic system disorders - Other 
(pancytopenia); Febrile neutropenia 
CARDIAC DISORDERS - Cardiac arrest; Ventricular tachycardia 
GASTROINTESTINAL DISORDERS - Constipation; Dry mouth; Ileus 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema limbs; Malaise; 
Multi-organ failure 
HEPATOBILIARY DISORDERS - Portal vein thrombosis 
INVESTIGATIONS - Lymphocyte count decreased; Neutrophil count decreased; Weight loss; White blood cell 
decreased 
METABOLISM AND NUTRITION DISORDERS - Hypophosphatemia; Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Bone pain; Muscle cramp: Pain in 
extremity 
NERVOUS SYSTEM DISORDERS - Headache 
PSYCHIATRIC DISORDERS - Confusion; Insomnia; Suicide attempt 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Breast pain 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchopulmonary hemorrhage; 
Pulmonary hypertension; Respiratory failure 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Dry skin2; Hyperhidrosis 
VASCULAR DISORDERS - Hypertension; Hypotension; Thromboembolic event 
 
Note: Atezolizumab (MPDL3280A) in combination with other agents could cause an exacerbation of any adverse 
event currently known to be caused by the other agent, or the combination may result in events never previously 
associated with either agent. 
7.1.2 
Adverse event list for paclitaxel 
Common adverse reactions are neutropenia, leukopenia, thrombocytopenia, anemia, infections, 
bleeding, hypersensitivity reactions, abnormal ECGs, peripheral neuropathy, myalgia/arthralgia, 
nausea, vomiting, diarrhea, alopecia, elevated liver enzymes, and injection site reaction. 
Please refer to the package insert for the comprehensive list of adverse events. 
7.2 
Adverse event characteristics  
• CTCAE term (AE description) and grade: The descriptions and grading scales 
found in the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 will be utilized until March 31, 2018 for AE reporting. CTCAE 
version 5.0 will be utilized for AE reporting beginning April 1, 2018. All appropriate 
treatment areas should have access to a copy of the CTCAE version 5.0. A copy of 
the CTCAE version 5.0 can be downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
• For expedited reporting purposes only:  
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed 
in the SPEER column, Section 7.1.1) should be reported through CTEP-
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AERS only if the grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined 
in Section 7.3.4. 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
7.3 
Expedited adverse event reporting 
7.3.1 
CTEP-AERS 
Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event Reporting 
System), accessed via the CTEP Web site (https://eapps-ctep.nci.nih.gov/ctepaers). The reporting 
procedures to be followed are presented in the “NCI Guidelines for Investigators: Adverse Event 
Reporting Requirements for DCTD (CTEP and CIP) and DCP INDs and IDEs” which can be 
downloaded from the CTEP Web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). These 
requirements are briefly outlined in the tables below (Section 7.3.3). 
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be made to 
CTEP by telephone at 301-897-7497. Once Internet connectivity is restored, the 24-hour 
notification phoned in must be entered electronically into CTEP-AERS by the original submitter 
at the site. 
7.3.2 
Distribution of adverse event reports 
CTEP-AERS is programmed for automatic electronic distribution of reports to the following 
individuals: Principal Investigator and Adverse Event Coordinator(s) (if applicable) of the 
Corresponding Organization or Lead Organization, the local treating physician, and the Reporter 
and Submitter. CTEP-AERS provides a copy feature for other e-mail recipients.  
7.3.3 
Expedited reporting guidelines 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
Note: A death on study requires both routine and expedited reporting, regardless of 
causality. Attribution to treatment or other cause must be provided. 
Death due to progressive disease should be reported as Grade 5 “Disease progression” under 
the system organ class (SOC) ”General disorders and administration site conditions.” Evidence 
that the death was a manifestation of underlying disease (e.g., radiological changes suggesting 
tumor growth or progression: clinical deterioration associated with a disease process) should be 
submitted.  
Phase 1 and Early Phase 2 Studies: Expedited Reporting Requirements for Adverse Events 
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7.3.4 
Adverse events of special interest in atezolizumab studies 
The following AEs are considered of special interest in patients receiving atezolizumab and must 
be reported expeditiously through CTEP-AERS, irrespective of regulatory seriousness criteria: 
• Pneumonitis 
• Colitis 
• Endocrinopathies: diabetes mellitus, pancreatitis, adrenal insufficiency, hyperthyroidism, 
hypophysitis, and adrenal insufficiency 
• Hepatitis, including AST or ALT > 10 x ULN 
• Systemic lupus erythematosus 
• Neurological disorders: Guillain-Barré syndrome, myasthenic syndrome or myasthenia 
gravis, and meningoencephalitis 
• Events suggestive of hypersensitivity, cytokine release, influenza-like illness, systemic 
inflammatory response syndrome, systemic immune activation, or infusion-related 
reactions 
• Nephritis 
• Ocular toxicities (e.g. uveitis, retinitis) 
• Myositis 
• Myopathies, including rhabdomyolysis 
• Grade >2 cardiac disorders (e.g. atrial fibrillation, myocarditis, pericarditis) 
• Vasculitis                                                                         
7.3.5 
Special situations reports 
• Data related to product usage during pregnancy or breastfeeding 
• Data related to overdose, abuse, misuse, inadvertent/erroneous administration, medication 
error or occupational exposure, with or without association with an AE/SAE 
• Data related to a suspected transmission of an infectious agent via a medicinal product 
(STIAMP) 
• Lack of therapeutic efficacy 
7.4 
Routine adverse event reporting 
All Adverse Events must be reported in routine study data submissions. AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents. AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave. For this trial the Adverse Event CRF is used for routine AE 
reporting in Rave. 
7.5 
Secondary malignancy 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A secondary 
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malignancy is not considered a metastasis of the initial neoplasm. 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS. Three options are available to 
describe the event:  
• Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML])  
• Myelodysplastic syndrome (MDS)  
• Treatment-related secondary malignancy  
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol. For this trial, use the 
Adverse Event CRF in Rave. 
7.6 
Second malignancy 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy). Second malignancies require ONLY routine AE 
reporting unless otherwise specified. 
 
 
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8. 
PHARMACEUTICAL INFORMATION 
A list of the adverse events and potential risks associated with the investigational or commercial 
agents administered in this study can be found in Section 7.1. 
8.1 
CTEP IND agent: Atezolizumab 
Other Names:  TecentriqTM, MPDL3280A 
Classification:  monoclonal antibody 
M.W.:  150 KD 
Mode of Action: anti-PD-L1 
8.1.1 
Description 
Atezolizumab is a humanized IgG1 monoclonal antibody consisting of two heavy chains (448 
amino acids) and two light chains (214 amino acids). Atezolizumab targets human PD-L1 and 
inhibits its interaction with its receptor PD-1. Atezolizumab also blocks the binding of PD-L1 to 
B7.1, an interaction that is reported to provide additional inhibitory signals to T cells [68].  
8.1.2 
How Supplied 
Atezolizumab is provided by Genentech/F.Hoffmann-La Roche LTD and distributed by the 
Pharmaceutical Management Branch, CTEP, NCI. The agent is supplied in a single-use, 20-mL 
glass vial as a colorless-to-slightly-yellow, sterile, preservative-free clear liquid solution intended 
for IV administration. Atezolizumab is formulated as 60 mg/mL atezolizumab in 20 mM 
histidine acetate, 120 mM sucrose, 0.04% polysorbate 20, at a pH of 5.8. The vial is designed to 
deliver 20 mL (1200 mg) of atezolizumab solution but may contain more than the stated volume 
to enable delivery of the entire 20 mL volume. 
8.1.3 
Preparation 
The prescribed dose of atezolizumab should be diluted in 250 mL 0.9% NaCl and infused 
through a 0.2 micrometer in-line filter. The IV bag may be constructed of PVC or PO; the IV 
infusion line may be constructed of PVC or PE; and the 0.2 micrometer in-line filter may be 
constructed of PES. The prepared solution may be stored at 2°C-8°C or room temperature for up 
to 8 hours. 
8.1.4 
Storage 
2°C-8°C (36°F-46°F) Vial contents should not be frozen or shaken and should be protected from 
direct sunlight. 
If a storage temperature excursion is identified, promptly return atezolizumab to 2°C-8°C (36°F-
46°F) and quarantine the supplies. Provide a detailed report of the excursion (including 
documentation of temperature monitoring and duration of the excursion) to 
pmbafterhours@mail.nih.gov for determination of suitability. 
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8.1.5 
Stability 
Stability studies are ongoing. 
CAUTION: No preservative is used in atezolizumab; therefore, the vial is intended for single use 
only. Discard any unused portion of drug remaining in a vial.  
8.1.6 
Route of Administration 
IV infusion. 
8.1.7 
Method of Administration 
Atezolizumab is administered as an intravenous infusion over 60 minutes. If the first infusion is 
tolerated, all subsequent infusions may be delivered over 30 minutes. Do not administer 
atezolizumab as an intravenous push or bolus.  No premedication is indicated for administration 
of Cycle 1 of atezolizumab. Patients who experience an infusion related reaction with Cycle 1 of 
atezolizumab may receive premedication with antihistamines or antipyretics/analgesics (e.g. 
acetaminophen) for subsequent infusions. 
8.1.8 
Potential Drug Interactions 
Cytochrome P450 enzymes as well as conjugation/glucuronidation reactions are not involved in 
the metabolism of atezolizumab. No drug interaction studies for atezolizumab have been 
conducted or are planned. There are no known interactions with other medicinal products or 
other form of interactions. 
8.1.9 
Patient Care Implication 
Female patients of childbearing potential should utilize contraception and take active measures to 
avoid pregnancy while undergoing atezolizumab treatment and for at least 5 months (150 days) 
after the last dose of atezolizumab. 
8.1.10 
Availability 
Atezolizumab is an investigational agent supplied to investigators by the Division of Cancer 
Treatment and Diagnosis (DCTD), NCI. 
8.1.11 
Atezolizumab ordering and agent accountability 
NCI-supplied agents may be requested by the Principal Investigator (or their authorized 
designee) at each participating institution. Pharmaceutical Management Branch (PMB) policy 
requires that agent be shipped directly to the institution where the patient is to be treated. PMB 
does not permit the transfer of agents between institutions (unless prior approval from PMB is 
obtained). The CTEP-assigned protocol number must be used for ordering all CTEP-supplied 
investigational agents. The responsible investigator at each participating institution must be 
registered with CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of 
Investigator), Biosketch/Curriculum Vitae, Supplemental Investigator Data Form (IDF), and 
Financial Disclosure Form (FDF). If there are several participating investigators at one 
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institution, CTEP-supplied investigational agents for the study should be ordered under the name 
of one lead investigator at that institution. 
In general, sites may order initial agent supplies when a subject is being screened for enrollment 
onto the study. 
Active CTEP-registered investigators and investigator-designated shipping designees and 
ordering designees can submit agent requests through the PMB Online Agent Order Processing 
(OAOP) application. Access to OAOP requires the establishment of a CTEP Identity and Access 
Management (IAM) account and the maintenance of an “active” account status and a “current” 
password. For questions about drug orders, transfers, returns, or accountability, call or email 
PMB any time. Refer to the PMB’s website for specific policies and guidelines related to agent 
management.  
8.1.12 
Atezolizumab inventory records 
The investigator, or a responsible party designated by the investigator, must maintain a careful 
record of the receipt, dispensing and final disposition of all agents received from the PMB using 
the appropriate NCI Investigational Agent (Drug) Accountability Record (DARF) available on 
the CTEP forms page. Store and maintain separate NCI Investigational Agent Accountability 
Records for each agent, strength, formulation and ordering investigator on this protocol. 
8.1.13 
Investigator Brochure Availability 
The current versions of the IBs for the agents will be accessible to site investigators and research 
staff through the PMB OAOP application.  Access to OAOP requires the establishment of a 
CTEP IAM account and the maintenance of an “active” account status and a “current” password.  
Questions about IB access may be directed to the PMB IB Coordinator via email. 
8.1.14 
CTEP useful links and contacts 
• CTEP Forms, Templates, Documents: http://ctep.cancer.gov/forms/ 
• NCI CTEP Investigator Registration: pmbregpend@ctep.nci.nih.gov 
• PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent management.htm  
• PMB Online Agent Order Processing (OAOP) application: https://eapps-
ctep.nci.nih.gov/OAOP/pages/login.jspx  
• CTEP Identity and Access Management (IAM) account: https://eapps-
ctep.nci.nih.gov/iam/ 
• CTEP Associate Registration and IAM account help: ctepreghelp@ctep.nci.nih.gov  
• PMB email: pmbafterhours@mail.nih.gov 
• PMB phone and hours of service: (240) 276-6575 Monday through Friday between 
8:30 am and 4:30 pm (ET) 
8.2 
Commercial agent: carboplatin 
8.2.1 
Product Description 
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Carboplatin is supplied as a sterile, pyrogen-free, 10 mg/mL aqueous solution of carboplatin. 
Carboplatin is a platinum coordination compound. The chemical name for carboplatin is 
platinum, diamine [1,1-cyclobutane-dicarboxylato(2-)-0,0’]-,(SP-4-2). It has a molecular formula 
of C6H12N2O4Pt and a molecular weight of 371.25. It is soluble in water at a rate of 
approximately 14 mg/mL, and the pH of a 1% solution is 5 to 7. It is virtually insoluble in 
ethanol, acetone, and dimethylacetamide. 
8.2.2 
Solution Preparation 
Please refer to the package insert for standard preparation instructions. 
8.2.3 
Route of Administration 
Aluminum reacts with carboplatin causing precipitate formation and loss of potency, therefore, 
needles or intravenous sets containing aluminum parts that may come in contact with the drug 
must not be used for the preparation or administration of carboplatin. 
Carboplatin will be administered over 30 minutes.  
8.2.4 
Agent Ordering 
Carboplatin is commercially available. 
8.2.5 
Prescribing Information 
Please refer to the package insert for full prescribing information on carboplatin. 
8.3 
Commercial agent: paclitaxel 
8.3.1 
Product Description 
Paclitaxel is obtained via a semi-synthetic process from Taxus baccata. The chemical name for 
paclitaxel is 5β,20-Epoxy-1,2α,4,7β,10β,13α-hexahydroxytax-11-en-9-one 4,10-diacetate 2-
benzoate 13-ester with (2R,3S)-N-benzoyl-3-phenylisoserine. Paclitaxel Injection, USP is a 
clear, colorless to slightly yellow viscous solution. It is supplied as a nonaqueous solution 
intended for dilution with a suitable parenteral fluid prior to intravenous infusion. Paclitaxel 
Injection, USP is available in 30 mg (5 mL), 100 mg (16.7 mL), and 300 mg (50 mL) multidose 
vials. Each mL of sterile nonpyrogenic solution contains 6 mg paclitaxel, USP, 527 mg of 
purified polyoxyl 35 castor oil, and 49.7% (v/v) dehydrated alcohol, USP. 
8.3.2 
Solution Preparation 
Please refer to the package insert for standard preparation instructions. 
8.3.3 
Route of administration 
Contact of the undiluted concentrate with plasticized PVC equipment or devices used to prepare 
solutions for infusion is not recommended. In order to minimize patient exposure to the 
plasticizer DEHP [di-(2-ethylhexyl)phthalate], which may be leached from PVC infusion bags or 
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sets, diluted paclitaxel solutions should be stored in bottles (glass, polypropylene) or plastic bags 
(polypropylene, polyolefin) and administered through polyethylene-lined administration sets. 
Administer paclitaxel as an IV infusion over 1 hour. 
8.3.4 
Agent ordering 
Paclitaxel is commercially available. 
8.3.5 
Prescribing Information 
Please refer to the package insert for full prescribing information on paclitaxel. 
 
 
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9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
The study design provides unique opportunities for tissue collection in the context of 
neoadjuvant chemotherapy therapy for triple negative breast cancer. Research core biopsies will 
be obtained at baseline, and after one cycle of therapy. Additional tumor tissue will be obtained 
at the time of surgery. PBMC will be obtained at baseline, after one and three cycles of therapy, 
and at the time of surgery. 
 
A summary of the correlative analyses and prioritization of sample use is provided below. Many 
of the correlative analyses planned will be conducted in collaboration with the Cancer Immune 
Monitoring and Analysis Center at Dana-Farber Cancer Institute (DFCI-CIMAC) and at 
Washington University as part of the Human Tumor Analysis Network (WU-HTAN).   
 
Sample Prioritization for Correlative Studies 
Priority 
Biomarker 
Name 
Assay 
(CLIA: Y/N) 
Use in protocol / 
Purpose  
Sample types and 
Time points of 
sample collection 
Mandatory or 
optional? 
Assay 
Lab  
1-tissue 
 
TIL 
percentage 
by H&E 
 
H&E 
(CLIA: N) 
Integral: 
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab (co-
primary endpoint). 
Correlate baseline TIL 
percentage with 
pathologic complete 
response (exploratory 
objective). 
Tumor 
FFPE  
 
Baseline, 
D18-22, 
surgical 
resection 
M 
DFCI-
CIMAC 
2-tissue 
TIL cell 
density 
(cells/mm2) 
by multiplex 
IF 
(CD3, CD8, 
CD20, CD4, 
FoxP3, 
PDL1, as 
tumor 
marker) 
 
IF 
(CLIA: N) 
Exploratory: 
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab (co-
primary endpoint).  
Correlate baseline 
immune cell percentage 
with pathologic 
complete response 
(exploratory objective). 
Tumor  
FFPE 
Baseline, 
D18-22, 
surgical 
resection 
M 
DFCI-
CIMAC 
3-tissue 
 
PD-L1 
expression 
 
(VENTANA 
PD-L1 
(SP142) 
Assay) 
IHC 
(CLIA: N)  
Exploratory: 
Correlate baseline PD-
L1 expression with 
pathologic complete 
response  
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab therapy  
Tumor 
FFPE 
 
Baseline, 
D18-22, 
surgical 
resection 
M 
Histo-
GeneX 
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Sample Prioritization for Correlative Studies 
Priority 
Biomarker 
Name 
Assay 
(CLIA: Y/N) 
Use in protocol / 
Purpose  
Sample types and 
Time points of 
sample collection 
Mandatory or 
optional? 
Assay 
Lab  
4-tissue 
Immune 
signature 
(RNA-Seq) 
RNA-Seq 
(CLIA: N) 
Exploratory: 
Correlate baseline 
immune signature with 
pathologic complete 
response  
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab therapy ( 
Tumor  
Frozen 
core 
 
Baseline, 
D18-22, 
Surgical 
resection 
M 
DFCI-
CIMAC 
5-tissue 
Immune 
signature 
(NanoString 
PanCancer 
Immune 
panel)  
Nanostring 
(Only if 
RNAseq is 
not 
performed) 
Exploratory: 
Correlate baseline 
immune signature with 
pathologic complete 
response  
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab therapy 
Tumor 
FFPE 
 
Baseline, 
D18-22, 
Surgical 
resection 
M 
DFCI-
CIMAC 
6-tissue 
Neoantigen 
load 
Tumor tissue 
and normal 
blood whole 
exome 
sequencing  
(CLIA: N) 
Exploratory: 
 
Correlate baseline 
neoantigen load with 
pathologic complete 
response 
Fresh 
tissue or 
FFPE 
 
Baseline, 
D18-22, 
Surgical 
resection 
O 
DFCI-
CIMAC 
7-tissue 
T cell 
receptor 
(TcR) 
repertoire 
analysis 
T cell 
receptor 
(TcR) 
sequencing 
Exploratory: 
 
Measure antitumor 
immune response based 
on T cell clonal changes 
following combination 
chemotherapy and 
atezolizumab therapy 
Fresh 
tissue or 
FFPE 
Baseline, 
D18-22, 
Surgical 
resection 
O 
DFCI-
CIMAC 
8-tissue 
Immune 
signature 
sn-RNA-Seq 
whole 
transcriptome 
Exploratory: 
Correlate baseline 
immune signature with 
pathologic complete 
response 
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab therapy 
Tumor  
Frozen 
core 
Baseline, 
D18-22, 
Surgical 
resection 
O 
WU-
HTAN 
(Gillande
rs, Ding) 
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Sample Prioritization for Correlative Studies 
Priority 
Biomarker 
Name 
Assay 
(CLIA: Y/N) 
Use in protocol / 
Purpose  
Sample types and 
Time points of 
sample collection 
Mandatory or 
optional? 
Assay 
Lab  
9-tissue 
Immune 
signature 
CODEX 
Exploratory: 
Correlate baseline 
immune signature with 
pathologic complete 
response  
Measure antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab therapy 
Tumor  
Frozen 
core 
Baseline, 
D18-22, 
Surgical 
resection 
O 
WU-
HTAN 
(Gillande
rs, Ding) 
1-blood 
Neoantigen 
load 
Tumor tissue 
and normal 
blood whole 
exome 
sequencing  
(CLIA: N) 
Exploratory: 
 
Correlate baseline 
neoantigen load with 
pathologic complete 
response 
blood 
Baseline 
or any 
other 
timepoint 
O 
DFCI-
CIMAC 
2-blood 
Neoantigen-
specific T 
cell response 
CyTOF or 
multiparamet
er flow 
cytometry 
with 
neoantigen-
specific 
tetramers or 
sn-RNA-Seq 
 
Exploratory: 
 
Measure neoantigen-
specific antitumor 
immune response 
following combination 
chemotherapy and 
atezolizumab therapy 
blood 
Baseline, 
D18-22, 
Surgical 
resection 
O 
Schreiber
/Gillande
rs, 
Immune 
Monitori
ng 
Laborator
y WUSM 
3-blood 
Peripheral 
blood 
immune 
reconstitutio
n  
CyTOF or 
multiparamet
er flow 
cytometry 
Exploratory: 
 
Assess peripheral blood 
immune reconstitution 
following combination 
chemotherapy and 
atezolizumab therapy  
blood 
Baseline, 
D18-22, 
Surgical 
resection 
O 
DFCI-
CIMAC 
4-blood 
T cell 
receptor 
(TcR) 
repertoire 
analysis  
T cell 
receptor 
(TcR) 
sequencing 
Exploratory: 
 
Measure antitumor 
immune response based 
on T cell clonal changes 
following combination 
chemotherapy and 
atezolizumab therapy 
blood 
Baseline, 
D18-22, 
Surgical 
resection 
O 
DFCI-
CIMAC 
 
9.1 
Integral correlative study 
9.1.1 
TIL percentage by H&E 
Rationale: TIL percentage is a well-described and validated histopathologic analysis that has 
been correlated with clinical response to adjuvant and neoadjuvant chemotherapy in patients with 
TNBC [44-46]. These studies used standardized methodology for visual assessment of TIL 
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percentage, and tissue specimens from patients in enrolled in phase 3 randomized clinical trials. 
The studies demonstrated that TIL percentage is associated with improved overall survival. This 
correlation was first reported using baseline samples from the BIG 2–98 trial [45] and 
subsequently independently confirmed in 481 TNBC sample prospectively collected during two 
phase III adjuvant randomized breast cancer trials (United States Eastern Cooperative Oncology 
Group trials 2197 and 1199) [44].  
An increase in the number of TILs has been shown to be associated with response to checkpoint 
inhibition therapy in multiple independent studies. For instance, in a prospective randomized trial 
of ipilimumab for patients with advanced melanoma where serial tumor biopsies were obtained, 
Hamid et al. demonstrated that 57.1% of patients in the benefit group had a post-treatment 
increase in TILs, whereas only 10.0% of patients in the non-benefit group had a post-treatment 
increase in TILs (p = 0.005) [60]. Similarly, Tumeh et al. studied tumor samples from 46 patients 
with metastatic melanoma obtained before and after therapy with pembrolizumab. In this study, 
they used quantitative immunohistochemistry to evaluate the number of CD8 T cells present in 
the tumor and observed that an increase in the number of CD8 T cells was strongly associated 
with the best percent change in tumor size as measured by CT scan (n=18, Spearman r = −0.75, P 
= 0.0002) [61]. Finally, Herbst et al. evaluated the safety, activity and biomarkers of PD-L1 
inhibition in patients treated with atezolizumab [35]. They found that after atezolizumab 
treatment, regressing lesions displayed a dense immune infiltrate. 
The primary objective of the clinical trial is to test the hypothesis that the combination of 
chemotherapy and atezolizumab will increase TIL percentage compared to chemotherapy alone 
in patients with newly diagnosed TNBC being treated with neoadjuvant chemotherapy. 
TIL percentage will be measured at baseline, and after initiation of therapy using a well validated 
histopathologic assay. The TIL percentage after initiation of therapy will be compared between 
patients receiving neoadjuvant chemotherapy alone (Arm A), and patients receiving neoadjuvant 
chemotherapy in combination with atezolizumab (Arm B). 
Tissue will be obtained at three time points (baseline, after initiation of therapy (day 18-22), and 
at the time of surgery), providing three opportunities to measure TIL percentage. We expect that 
TIL percentage will be readily measured at baseline and at day 22, but that TIL percentage may 
be difficult to measure at the time of surgery. We anticipate that the pCR may be 50%, or greater 
depending on the arm.  
As this is a randomized clinical trial, we anticipate that the baseline TIL percentage will be 
similar between the two arms. As such, for the primary endpoint, we will compare the TIL 
percentage between arms at day 22. We hypothesize that the TIL percentage will be increased in 
Arm B (chemotherapy plus atezolizumab). 
At each time point, two cores will be placed into FFPE. Both cores will be assessed by H&E for 
the presence of invasive breast cancer and for TIL percentage. If no invasive cancer is present in 
either of the two FFPE cores at day 22, the sample will be considered inevaluable. If invasive 
cancer is present in only one of the two FFPE cores, the sample will be considered evaluable, 
and TIL percentage will be determined based on the FFPE core containing invasive breast 
cancer. If invasive cancer is present in both cores, TIL percentage will be assessed independently 
in the two cores and the result will be averaged between the two cores in order to minimize 
sampling bias as a potential confounder. Please note if the day 22 sample is inevaluable, the 
patient is inevaluable for the primary endpoint and will be replaced so that at least 60 patients 
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NCI Protocol #: 10013 
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who are evaluable for the primary endpoint are enrolled.  These patients will continue on 
protocol and will be evaluated for the secondary and exploratory endpoints. 
Hypothesis: The combination of chemotherapy and atezolizumab will increase TIL percentage, 
and pathologic complete response rate compared to chemotherapy alone in patients with newly 
diagnosed TNBC being treated with neoadjuvant chemotherapy. 
Assay methodology: TIL percentage will be evaluated as described by Wimberly et al. [69] and a 
recent International Working Group [70].  
TIL percentage will be assessed in collaboration with Drs.
who 
 the DFCI 
Tissue Biomarker Laboratory a member of the NCI Cancer
onitoring and Analysis 
Centers (CIMACs) - Cancer Immunologic Data Commons (CIDC) Network. Hematoxylin and 
eosin (H&E) stains are routinely performed for quality control for IHC staining. H&E staining 
will allow the assessments for: Viable Tissue (% nucleated cells), Viable Tumor cells (% 
nucleated cells), Lymphocyte Influx (0- to 3+), Necrosis (% area), Fibrosis (% nucleated cells). 
TIL percentage can also be calculated as detailed below: 
Protocol for assessing tumor-infiltrating lymphocytes (TILs) in breast cancer 
To assess tumor-infiltrating lymphocytes (TILs) in breast cancer, we will follow the protocol 
published by Salgado et al, 2015 [70]. More specifically, to report the percentage of TILs for the 
stromal compartment we will follow these steps: 
Step 1. We will define the area for TILs evaluation 
The TILs will be evaluated within the borders of the invasive tumor including the invasive edge 
and a single value reported. TILs outside of the tumor borders, tumor zones with crush artifacts, 
necrosis and hyalinization will be excluded. 
Step 2. We will scan tumor at low magnification, focusing on the tumor stroma and stromal 
TILs. 
We plan to analyze only one section per patient, with the parameters of the section being 4-5μM, 
and we will use a x200-400 magnification to assess the average TILs in the stromal area by the 
pathologist who will report his score in 10% increments (0-100%) in as much detail as possible. 
For assessment of percentage values, the dissociated growth pattern of lymphocytes will be taken 
into account.  
Step 3. We will determine the type of inflammatory infiltrate 
We are only going to score only mononuclear cells (lymphocytes and plasma cells). This 
analysis will not include granulocytic infiltrates in necrotic areas. 
Step 4. We will include the tumor in one of three groups based on low magnification and 
we will assess % stromal TILs.  
Group A: tumor with no/minimal immune cells (0-10% stromal TILs). 
Group B: tumor with intermediate/heterogeneous infiltrate (10-40% stromal TILs). 
Group C: Tumor with high immune infiltrate (40-90% stromal TILs). 
Step 5. We will report the percentage of stromal lymphocytes  
We will report the average of the stromal area and will not focus on hotspots. 
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For intermediate groups, we will evaluate different areas at higher magnification, taking into 
consideration that lymphocytes do not form aggregates, therefore even with 90-100% stroma 
TILs there will still be some space between the individual lymphocytes. 
Of note, measurement of TIL percentage will be performed by two pathologists in 10% 
increments. The SOP has been reviewed by the CTEP Biomarker Review Committee and 
harmonized with investigators at Dana Farber Cancer Institute (Rodig) and at Yale University 
(Schalper). 
To evaluate inter-laboratory reproducibility of TIL assessment in the H&E biopsy specimens, we 
will perform the following analyses: 
The precision of each biomarker in each lab will be measured in terms of standard deviation. The 
repeatability and between-lab reproducibility for each biomarker will also be assessed using the 
following linear mixed model,  
e
B
y
+
+
= µ
 
µ : general expectation (population mean)  
B: laboratory component of variation 
e: random error  
Expectation and variance of B are assumed to be 0 and 
( )
B
V
 respectively. Expectation of e is 
assumed to be 0 and its variance, ( )
e
V
, is assumed to be equal in all laboratories. The standard 
deviation of repeatability,
( )
e
V
, represents precision under the hypothetical condition where 
independent measures are obtained with the same method on the identical tests in the same 
laboratory by the same technician using the same equipment within short intervals of time. While 
the reproducibility standard deviation,
( )
( )e
V
B
V
+
, measures the precision under conditions 
where measures are obtained with the same method on identical tests in different laboratories 
with different technicians using different equipment. 
The overall agreement of TIL percentage between two cores will also be assessed using 
intraclass correlation of coefficients. 
TIL percentage will also be measured by multiplexed quantitative fluorescence (QIF) (see 
Section 9.2.1). There is a concern that measurement of TIL percentage by H&E is only 
semiquantitative and subject to interobserver variation. Measurement of TIL percentage by two 
protocols, and in collaboration with two groups will address this issue. 
Investigator’s Experience and Competence with the Assay: TIL percentage will be assessed in 
collaboration with Drs. 
 at Dana Farber Cancer Institute, and Dr.
at 
Yale University Cancer Center.  
Drs.
and
are experienced clinical pathologists with experience 
evaluating breast specimens. The assay will be performed in a CLIA-certified laboratory.  
Justification for Number of Patients and Specimens: Based on a two-sample t-test, the designed 
sample size (20 patients in Arm A and 40 patients in Arm B) provides 80% power at 1-sided 
alpha = 0.1 to detect a minimum of ~15% difference between the treatment arms. We expect this 
will be a clinically meaningful difference. Data from several phase III trials, have demonstrated 
that for every 10% increase in TIL percentage at baseline, there is a 15% to 20% increase in DFS 
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and OS in TNBC patients [44-46]. 
 
Collection of specimens 
Four research core biopsies will be collected prior to treatment and after one cycle of therapy. At 
each time point, two cores will be placed in 10% buffered formalin and these will provide 
material for this assay. Please see Section 5.5 for additional details on specimen collection.  
 
Handling of specimens 
The research core biopsies will be kept in 10% buffered formalin and shipped same-day to the 
Tissue Procurement Core. If they cannot be shipped on the day of collection, the research core 
biopsies may be kept in 10% buffered formalin overnight for fixation of tissue, followed by 
dehydration and paraffin infiltration using standard procedures. Each core is prepared into an 
individual paraffin block. Each block should be labeled with 
• Study number 
• Subject ID number 
• Date of specimen acquisition 
Blocks will be shipped in batch to the Tissue Procurement Core Facility at WUSM as detailed 
below. 
 
Shipping of specimen(s) 
Specimens should be shipped to the Washington University Tissue Procurement Facility at the 
address below: 
425 S. Euclid Ave., Room 5120 
St. Louis, MO 63110-1005 
Phone: 314-454-7615 
Email: tbank@wudosis.wustl.edu  
All samples should be labeled with institutional study number, subject ID number, date of 
specimen acquisition, sample collection time and patient initials. They should be accompanied 
by a specimen submission form. 
Specimens may be sent to the Tissue Procurement Facility on Monday through Thursday for next 
day deliver. The Tissue Procurement Facility cannot receive specimens on Saturdays, 
Sundays, or holidays. Do not send specimens on Friday, Saturday, or the day before a 
holiday. 
Arrange for Federal Express pick-up through your usual institutional procedures. On the day that 
specimens are sent, please email the Tissue Procurement Facility at tbank@wustl.edu as 
described in the specimen shipping instructions, including the tracking number of the shipment 
and number of kits shipped. Ship blocks at room temperature to the Tissue Procurement Facility 
at Washington University and attach a copy of the Block Shipment Log. 
9.2 
Exploratory correlative studies 
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9.2.1 
TIL Percentage by multiplexed quantitative fluorescence (QIF) 
Rationale: TIL percentage is a well-described and validated histopathologic analysis that has 
been correlated with clinical response to adjuvant and neoadjuvant chemotherapy in patients with 
TNBC [44-46]. However, there is a concern that measurement of TIL percentage by H&E is only 
semiquantitative and subject to interobserver variation. We will also measure TIL percentage by 
multiplexed quantitative fluorescence (QIF). 
Hypothesis: The combination of chemotherapy and atezolizumab will increase TIL percentage, 
and pathologic complete response rate compared to chemotherapy alone in patients with newly 
diagnosed TNBC being treated with neoadjuvant chemotherapy. 
Assay methodology: TIL percentage by multiplexed quantitative fluorescence (QIF) will be 
evaluated in the DFCI Tissue Biomarker Laboratory led by Dr.
 The DFCI Tissue 
Biomarker Laboratory will conduct multiplex immunofluorescence biomarker imaging for multi-
label analysis of formalin- FFPE tissue biopsy samples. The PerkinElmer’s multiplex biomarker 
imaging systems will be used to precisely measure and quantify multiple fluorescent molecular 
markers simultaneously, even when co-localized within a single tissue section. The data for each 
marker is spectrally unmixed, generating clear and accurate images for each of the individual 
labels in a multi-labeled tissue section with no crosstalk. Specifically, we will use the Opal 
chemistry and multispectral microscopy Vectra™ 3.0 and Polaris™ systems (Perkin-Elmer), 
which includes the Nuance software; analysis will be performed using the inForm software. The 
proposed panels for the trial samples include: CD3, CD8, CD20, CD4, FoxP3, PDL1. T-cell 
subpopulations are defined by expression of specific markers (CD3, CD4, CD8, FoxP3), B cells 
by CD20, and all immune populations are evaluated as cell density per tumor tissue (number of 
positive cells by mm square of tumor area. The staining procedure will be performed by 
specialized technicians under pathologist supervision, and the scanning and analysis is done by 
senior scientists and a pathologist trained in the use of Vectra and InForm.  Finally, the data is 
consolidated using Inform Image Analysis Software (PerkinElmer) for the final report.  
Investigator’s Experience and Competence with the Assay: TIL percentage by multiplexed 
quantitative fluorescence (QIF) will be assessed in collaboration with Drs. 
at Dana 
Farber Cancer Institute, a Cancer Immune Monitoring and Analysis Centers (CIMACS) 
laboratory that provides state-of-the-art analyses for genomic, phenotypic and functional 
characterization of responses of patients in early phase clinical trials using analytically-validated 
assays.  
Justification for Number of Patients and Specimens: Based on a two-sample t-test, the designed 
sample size (20 patients in Arm A and 40 patients in Arm B) provides 80% power at 1-sided 
alpha = 0.1 to detect a minimum of ~15% difference between the treatment arms. Note that for 
TIL percentage and neoantigen-specific T cell response, targeting the differences between two 
treatment arms, the power justification was based on an alpha = 0.1 (see Section 13.1 for the 
rationale for this alpha level). For the PD-L1 expression, immune signature, and neoantigen load, 
the power justification was based on the more conventional alpha = 0.05. 
 
Collection of specimens 
Four research core biopsies will be collected prior to treatment and after one cycle of therapy. At 
each time point, two cores will be placed in 10% buffered formalin and these will provide 
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NCI Protocol #: 10013 
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material for this assay. Please see Section 5.5 for additional details on specimen collection.  
 
Handling of specimens 
The research core biopsies will be kept in 10% buffered formalin and shipped same-day to the 
Tissue Procurement Core. If they cannot be shipped on the day of collection, the research core 
biopsies may be kept in 10% buffered formalin overnight for fixation of tissue, followed by 
dehydration and paraffin infiltration using standard procedures. Each core is prepared into an 
individual paraffin block. Each block should be labeled with 
• Study number 
• Subject ID number 
• Date of specimen acquisition 
Blocks will be shipped in batch to the Tissue Procurement Core Facility at WUSM as detailed 
below. 
 
Shipping of specimen(s) 
Please see Section 9.1.1.3 for detailed instructions on shipping of samples to the Tissue 
Procurement Core Facility at WUSM. 
9.2.2 
PDL1 Expression 
Rationale: PD-L1 expression is higher in TNBC than other breast cancer subtypes [47, 48]. We 
have examined the expression of PD-1 and PD-L1 in the common molecular subtypes of breast 
cancer using a well annotated human breast cancer tissue array [48, 49]. These studies 
demonstrate that expression of PD-1 on tumor-infiltrating lymphocytes and/or PD-L1 on breast 
cancers is more common in TNBC, and expression of these proteins is associated with a poor 
prognosis. Other investigators have also documented increased expression of PD-L1 in TNBC 
[47]. 
PD-L1 expression has also been demonstrated to be a biomarker for response to atezolizumab 
therapy [35]. Through serial on-treatment tumor biopsy analysis, a decrease in tumor burden was 
associated with increased PD-L1 expression at baseline, and an increase in PD-L1 expression on 
tumor-infiltrating immune cells following initiation of therapy [35]. Combined, these studies 
provide strong rationale for assessing PD-L1 levels at baseline and after one cycle of therapy. 
Hypothesis: (1) PD-L1 expression on tumor-infiltrating immune cells at baseline predicts 
pathologic complete response. (2) Increased PD-L1 expression on tumor-infiltrating immune 
cells after one cycle of therapy predicts pathologic complete response. 
Assay methodology: PD-L1 expression on tumor-infiltrating immune cells and on tumor cells 
will be performed at HistoGeneX, using the VENTANA PD-L1 (SP142) Assay that is FDA 
approved for PD-L1 expression. 
Investigator’s Experience and Competence with the Assay: HistoGeneX Laboratories is a CAP 
and CLIA accredited global laboratory system that serves pharma and biotech drug development 
sponsors and functions as a diagnostic laboratory for oncology offices worldwide. They have 
validated the VENTANA PD-L1 (SP142) immunohistochemistry assay for clinical use. 
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Justification for Number of Patients and Specimens: PD-L1 scoring will include cut-point 
analyses of ≥ 1% and ≥ 5%, as these thresholds have been used in previous studies. We will also 
test other thresholds using a ROC analysis as detailed below. 
The predictive ability of PD-L1 expression on pathologic complete response (pCR) will be 
described as the area under ROC curves (AUC). The designed sample size of 60 patients (~30 
pCr and ~30 non-pCR) provides 80% power at 1-sided alpha=0.05 to detect a minimum AUC of 
0.68 (against AUC = 0.50, or no discriminating information). This was computed using the SAS 
macro developed by 
and assuming the PD-L1 expression measured at an ordinal scale 
[http://www.bio.ri.ccf.org/html/rocanalysis.html].  
 
Collection of specimens 
Four research core biopsies will be collected prior to treatment and after one cycle of therapy. At 
each time point, two cores will be placed in 10% buffered formalin and these will provide 
material for this assay. Please see Section 5.5 for additional details on specimen collection.  
 
Handling of specimens 
The research core biopsies will be kept in 10% buffered formalin and shipped same-day to the 
Tissue Procurement Core. If they cannot be shipped on the day of collection, the research core 
biopsies may be kept in 10% buffered formalin overnight for fixation of tissue, followed by 
dehydration and paraffin infiltration using standard procedures. Each core is prepared into an 
individual paraffin block. Each block should be labeled with 
• Study number 
• Subject ID number 
• Date of specimen acquisition 
Blocks will be shipped in batch to the Tissue Procurement Core Facility at WUSM as detailed 
below.  The Tissue Procurement Core at WUSM will ship specimens to HistoGeneX following 
the directions in the HistoGeneX analysis plan. 
 
Shipping of specimen(s) 
Please see Section 9.1.1.3 for shipping of samples. 
9.2.3 
Immune signature 
Rationale: Tumor infiltrating lymphocytes (TILs) are more common in TNBC than in other 
breast cancer subtypes, and TILs are associated with improved outcome in TNBC following 
adjuvant, or neoadjuvant chemotherapy [44-46]. The association between TILs and improved 
outcome in TNBC suggests that the adaptive immune system contributes to the response to 
chemotherapy.  
One of the underlying hypotheses of this clinical trial is that PD-1/PD-L1 signaling restrains 
immune responses in TNBC, and atezolizumab therapy will enhance immune responses in the 
context of neoadjuvant chemotherapy. 
Denkert et al. recently defined a mRNA immune signature that correlated with pathologic 
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complete response in the GeparSixto breast cancer clinical trial. Twelve immunologically 
relevant mRNA markers were selected for detailed evaluation in breast cancer tissue, including 
T-cell markers, B-cell markers, chemokines, and immune checkpoint parameters [46]. 
Gene expression analysis of tumor biopsies during anti-PD-L1 treatment showed a dramatic 
increase in CD8 and Th1-related cytokines and activation markers that corresponded to reduced 
tumor burden [35]. 
In NSCLC, B- and NK-cell signatures were associated with clinical benefit [64]. 
In bladder cancer, baseline immune signature associated with an effector T cell signature 
(including CD8A, GZMA, IFNG) and/or NK gene signature (NKG2 family members) were 
associated with clinical benefit [65]. 
Research core biopsies will be subjected to RNA extraction and analysis to assess expression of 
immune-related genes. The NanoString technology is a variation on the DNA microarray, and 
permits analysis of up to 800 transcripts in a single reaction [71]. This platform has been 
validated for application to both RNA from frozen tissue and RNA extracted from FFPE samples 
[72-75]. The nCounter®PanCancer Immune Profile Panel developed by NanoString, Inc. allows 
analysis of 770 genes for 24 different immune cell types and populations, 30 common cancer 
antigens and functional markers including checkpoint blockade genes 
(http://www.nanostring.com/). 
Hypotheses: (1) Immune signature at baseline predicts pathologic complete response. (2) A 
change in the immune signature after one cycle of therapy predicts pathologic complete 
response. 
Assay methodology: Several immune signatures will be assessed, including the immune 
signatures cited above, and immune signatures developed by Genentech using RNA-Seq from 
biopsy specimens collected in OCT blocks. RNA will be extracted from OCT blocks at the 
Tissue Procurement Facility using the RNeasy® kit (Qiagen). RNA will be analyzed at the DFCI 
CIMAC Translational Immunogenomics Laboratory led by Dr.
in collaboration 
with the Broad Institute using Tru-Seq Strand Specific Large Insert RNA Sequencing. The Tru-
Seq platform includes plating, poly-A selection and strand specific cDNA synthesis, library 
preparation (450-550bp insert size), and sequencing (101bp paired reads); sequence coverage is 
up to 50 million paired reads or 50 million total reads.  
Whole transcriptome analyses for sn-RNA-seq will also be performed using the 10x Genomics 
platform as previously reported by Drs. Ding.and Gillanders at the Washington University 
Human Tumor Atlas Research Center for HTAN (WU-HTAN)[76].   
Alternatively, if specimens from OCT blocks are limiting, the Nanostring PanCancer Immune 
panel may be completed from 100ng of total RNA isolated from frozen tissue or FFPE tissue. 
RNA will be analyzed using the nCounter analysis platform per the manufacturer’s instructions 
at the DFCI Tissue Biomarker Laboratory led by Dr. 
 DFCI technicians will follow 
NanoString™ nCounter® protocols in accordance with the manufacturer’s instructions. The data 
will be analyzed using Nanostring nSolver Analysis Software for the final report.  
Investigator’s Experience and Competence with the Assay: DFCI CIMAC uses the PanCancer 
Immune Profiling Panel, an nCounter panel from NanoString™ optimized to develop profiles of 
the human immune response in all cancer types. This 770-gene panel includes markers for 24 
different immune cell types and populations, 30 common cancer antigens, key checkpoint 
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blockade genes, and genes representing all categories of immune responses. 
The WU HTAN Co-PIs Gillanders and Ding have established sn-RNA-Seq and CODEX assays 
optimized for core biopsy sized specimens that have been used to evaluate immune signatures in 
pancreas and breast cancer tissues.  The Ding lab has extensive experience generating high 
quality snRNA-seq data across several tissue types using 10x Genomics platform. In total we 
have generated data for over 500 samples with over 70 specifically relevant for breast cancer. 
Instrumentation, methods, and bioinformatic tools are in-place for all data to be generated. The 
Ding lab also performed successful snRNA-seq experiments on core biopsies of breast cancer 
and pancreatic cancer retrieving from 5 to 10 thousand cells with ~2,000-4,000 median genes per 
cell indicative of high data quality. CODEX (CO-Detection by indexing) is a relatively new 
multiplex imaging system that utilizes antibodies conjugated to oligonucleotide barcodes, which 
are then visualized via fluorescently labeled reporters [77, 78]]. Unlike traditional multiplex IF, 
all antibodies can be stained simultaneously, which minimizes antigen decay. The Ding lab has 
developed a panel of DNA-barcoded antibodies for common cell type markers, proliferation 
markers, breast cancer subtype markers, ductal carcinoma in-situ markers and immune cell state 
markers.  
Justification for Number of Patients and Specimens: The predictive ability of immune signature 
on pathologic complete response (pCR) will also be described as the area under ROC curves 
(AUC). Sample size justification will be similar to that of PD-L1 expression.  
Collection of specimens 
Four research core biopsies will be collected prior to treatment and after one cycle of therapy. At 
each time point, two cores will be immediately frozen in separate OCT blocks and these will 
provide material for this assay. Please see Section 5.5 for additional details on specimen 
collection.  
 
Handling of specimens 
The research core biopsies will be stored at -70oC on site. Each block should be labeled with 
•
Study number
•
Subject ID number
•
Date of specimen acquisition
Blocks will be shipped in batch to the Tissue Procurement Core Facility at WUSM as detailed 
below. 
 
Shipping of specimen(s) 
Please see Section 9.1.1.3 for shipping of samples. 
9.2.4 
Neoantigen load 
Rationale: Neoantigen load has been correlated with response to checkpoint blockade therapy in 
preclinical models [66] and human clinical trials [36]. We have developed robust next-generation 
sequencing strategies for the identification of neoantigens [79].  
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Hypothesis: Neoantigen load predicts pathologic complete response. 
Assay methodology: Neoantigen load will be measured as previously described [79]. 
The DFCI CIMAC Translational Immunogenomics Laboratory led by Dr.
in 
collaboration with the Broad Institute will conduct the WES, which is ideal for unbiased 
detection of somatic mutations and copy number changes in tumor samples. Analysis will be 
performed on genomic DNA, fresh frozen tissue, FFPE scrolls etc.as necessitated by specimen 
availability and yields. The DFCI CIMAC/Broad’s process includes hybrid capture (Illumina 
Rapid Capture Enrichment – 37Mb target), sequencing (Illumina, 76bp paired reads), and a 
sample identification quality control check, as well as data storage (5 years). Our hybrid 
selection libraries for deep somatic exomes typically meet or exceed 85% of targets at 50X, and 
for standard exomes, meet or exceed 80% at 20x. The DFCI/Broad CIMAC has the ability to 
process up to 188 samples per week with no minimum batch size. Processing times vary and 
depend on current demand.  
We have developed and optimized an epitope prediction algorithm for the identification and 
prioritization of neoantigens. This optimized epitope prediction algorithm is described below and 
in our previous publications [66, 79]. We have established this algorithm in collaboration with 
Dr.
 an internationally-known expert in tumor immunology [80-88].
and 
were one of the first to use next generation sequencing technologies to identify 
neoantigens, demonstrating that these antigens are important tumor rejection antigens [80]. 
and Gillanders have now optimized the epitope prediction algorithm and have 
demonstrated that cancer vaccines targeting neoantigens are associated with antitumor immunity 
[66].  
The goal of the optimized epitope prediction algorithm is to identify neoantigens and quantify 
the neoantigen load. The algorithm uses a combination of binding algorithms and processing 
algorithms. 
Mutations that are expressed in the breast cancer will be identified using the sequencing data 
analysis pipeline in collaboration with Li Ding, Ph. D., an expert in genomic analysis at 
Washington University. The predicted amino acid sequences corresponding to the expressed 
mutations will be pipelined through three class I MHC epitope-binding algorithms provided by 
the Immune Epitope Database and Analysis Resource (http://www.immuneepitope.org): (i) 
Stabilized Matrix Method (SMM) [89], (ii) Artificial Neural Network (ANN) [90], and (iii) 
NetMHCpan [91]. 
A prioritized list of binding epitopes (i.e. IC50 < 500 nM) will be generated after calculating the 
median binding affinity value for each mutant sequence (affinity value expressed as 1/IC50 x 
100).  
Investigator’s Experience and Competence with the Assay: The DFCI CIMAC/Broad Institute 
employs state of the art sequencing platforms and is a work leader in genomic analysis. Drs. 
and Gillanders have considerable expertise in identifying neoantigens using 
sequencing technologies [66, 79, 80].  Dr. Ding’s team at Washington University has developed 
a collection of widely-used computational tools for genomics at McDonnell Genome Institute, 
including VarScan, SomaticSniper, SciClone, BreakDancer, BreakFusion, MSIsensor, Pindel-C, 
GenomeVIP, HotSpot3D, and MuSiC.  Dr. Ding has also played significant roles in The Cancer 
Genome Atlas (TCGA), the International Cancer Genome Consortium (ICGC), and the Clinical 
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Proteomic Tumor Analysis Consortium (CPTAC), PDX (patient-derived xenografts) 
Development and Trial Centers Research Network (PDXNet).  
Dr. Ding and Dr. Gillanders are co-PIs on the Human Tumor Atlas Research Center grant,  an 
NCI  Cancer Moonshot initiative.  Dr. Ding will work across the Cancer Moonshot network with 
Dr. 
 at DFCI CIMAC to complete the interpretation of the genomic correlative data 
for this study. 
Justification for Number of Patients and Specimens: The predictive ability of neoantigen load on 
pathologic complete response (pCR) will also be described as the area under ROC curves 
(AUC). Sample size justification will be similar to that of PD-L1 expression. 
 
Collection of specimens 
Peripheral blood specimens will be collected pretreatment, after cycles 1, and 3 of therapy, and at 
the time of surgery as detailed in Section 5.4.4. The risks of venipuncture are minimal. For each 
subject six 10mL green-top (sodium heparin) tubes (BD Vacutainer, Catalog # 366480) will be 
collected at each time point. 
Four research core biopsies will be collected prior to treatment. Two cores will be immediately 
frozen in separate OCT blocks and these, along with the PBMCs from any timepoint will provide 
material for this assay. Two core biopsies will also be collected in 10% buffered formalin and 
will provide an alternate source of material if there is insufficient yield from OCT blocks. Please 
see Section 5.5 for additional details on specimen collection.  
 
Handling of specimens 
The research core biopsies will be stored at -70oC on site. Each block should be labeled with: 
• Study number 
• Subject ID number 
• Date of specimen acquisition 
Blocks will be shipped in batch to the Tissue Procurement Core Facility at WUSM as detailed 
below. 
 
Shipping of specimen(s) 
Please see Section 9.1.1.3 for shipping of samples. 
9.2.5 T cell receptor (TcR) sequencing repertoire analysis 
Rationale: The T cell receptor (TCR) repertoire is an important component of the adaptive 
immune response and recognition of antigens. Successful activation of the anti-tumoral response 
is dependent on the binding of the TCR to the neoantigen-major histocompatibility complex; 
thus a more diverse TCR repertoire has a greater potential for recognizing neoantigens. Recent 
studies examining the TCR repertoire in the context of cancer immunotherapy suggest that the 
TCR clonal repertoire may be modulated by immunotherapy and correlated with patient response 
in breast cancer[92] and other cancers [93-95]. We will conduct an exploratory analysis to 
evaluate the clonal alteration and immune response by profiling the TCRs circulating in the 
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peripheral blood, and within the tumor, at baseline and following one cycle of therapy, in 
collaboration with the CIMAC DFCI Translational Immunogenomics Laboratory.  
 
Hypothesis: We hypothesize that the TCR repertoire in patients will be altered after one cycle of 
therapy. 
 
Assay methodogy: The DFCI CIMAC Translational Immunogenomics Laboratory led by Drs. 
and
offers a method for amplification of TCR CDR3 segments 
from bulk RNA derived from PBMC and fresh frozen specimens. This RNA-based method 
amplifies TCR alpha and beta CDR3 segments, adding sample-specific barcodes, and preparing 
libraries suitable for loading on Illumina sequencers to detect all productive T-cell receptor alpha 
variable region (TRAV) and T-cell receptor beta variable region (TRBV) T-cell subfamilies. In 
addition, the NCI and CIMACs (including DFCI CIMAC) are also considering TCR sequencing 
from bulk DNA derived from PBMC and FFPE specimens. This DNA-based method  utilizes 
validated kits from Adaptive Technologies (Seattle, WA, ImmunoSeq Survey or Deep 
Sequencing) to identify human TCR beta clonotypes. 
 
For CTEP 10013, the biobank will perform dual RNA/DNA extraction from blood/tissue and 
send nucleic acid material to the DFCI CIMAC. The DFCI CIMAC will evaluate specimen 
quality/quantity and decide upon the most suitable assay (RNA-based TCRseq vs. DNA-based 
TCRseq) to be analyzed on-site at the DFCI CIMAC in consultation with the trial team, NCI, and 
the CIMAC-CIDC network.     
 
9.2.5.1 
Collection of specimens 
Peripheral blood specimens will be collected pretreatment, after one cycles 1, and 3 of therapy, 
and at the time of surgery as detailed in Section 5.4.4. The risks of venipuncture are minimal. 
For each subject six 10mL green-top (sodium heparin) tubes (BD Vacutainer, Catalog # 366480) 
will be collected at each time point.  
 
Four research core biopsies will be collected prior to treatment. Two cores will be immediately 
frozen in separate OCT blocks and these, along with PBMCs from baseline and post-cycle 1 will 
provide material for this assay. Please see Section 5.5 for additional details on specimen 
collection.  
 
9.2.5.2 
Handling of specimens 
 
The research core biopsies will be stored at -70oC on site. Each block should be labeled with: 
• Study number 
• Subject ID number 
• Date of specimen acquisition 
 
Shipping of specimen(s) 
Please see Section 9.1.1.3 for shipping of samples. 
9.2.6 
Neoantigen-specific T cell response 
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Rationale: Once we have identified and prioritized neoantigens (Section 9.2.3), we will generate 
MHC class I tetramers by UV-induced epitope exchange, and perform multiparameter flow 
cytometry, or time-of-flight mass spectrometry (CyTOF) to determine the frequency and 
function of neoantigen-specific T cells in the peripheral blood of patients with TNBC, or if 
frequency and function of neoantigen-specific T cells changes during treatment. We developed a 
high throughput assay system in collaboration with Dr.
and 
 at The Netherlands Cancer Institute in Amsterdam to develop bar-coded MHC class I 
tetramers by UV-induced epitope exchange capable of recognizing multiple different neoantigen-
specific T cells simultaneously. 
Hypothesis: Atezolizumab therapy is associated with an increase in the frequency and function 
of neoantigen-specific T cells in the peripheral blood of patients. 
Assay methodology: We will use peptide-MHC tetramers refolded with conditional ligands that 
can be exchanged for any desired peptide upon exposure to ultraviolet light [96]. Briefly, in 
order to generate a desired MHC class I allele, recombinant human MHC class I heavy chain and 
β2 microglobulin light chains are first produced in Escherichia coli, isolated as inclusion bodies, 
and refolded with photocleavable allele-specific conditional ligands as described [96]. Peptide-
MHC monomers are then desalted, biotinylated and purified by gel filtration FPLC. For 
ultraviolet-induced ligand exchange and combinatorial encoding, peptide-MHC monomers are 
subjected to long-wave UV light for one hour in the presence of conventional peptides of desired 
sequence prior to tetramerization by the addition of titrated amounts of streptavidin-
fluorochrome conjugates [97]. Peripheral blood mononuclear cells are then stained in a 
combinatorial fashion such that each tetramer is labeled with two separate fluorochromes, 
allowing for the staining of up to 28 tetramers in one individual sample in two-color codes by 
utilizing eight separate streptavidin-fluorochrome conjugates. 
Peptide-MHC tetramers will be constructed by microscale UV-mediated peptide exchange for 
each neoantigen identified for which a suitable MHC class I allele is available and used to 
identify neoantigen-specific CD8 T cells. For these studies, we will make use of conventional 
flow cytometry as well as the CyTOF2 instrument in the Center for Human Immunology and 
Immunotherapy Programs (CHIIPs) at WUSM. This technique allows the monitoring of 
expression of up to 49 parameters on a single cell using isotopically tagged probes, which will 
allow the simultaneous measurement not only of the presence of tumor-specific CTL, but also 
unprecedented analysis of their function, such as expression of the surface molecules LAG-3 and 
TIM-3 that correlate with CD8 T-cell dysfunction, measurement of intracellular cytokine 
production, and assessment of surface molecules to establish whether neoantigen-specific CD8 T 
cells adopt a naïve or antigen-experienced phenotype. 
Investigator’s Experience and Competence with the Assay: Drs. 
 and Gillanders have 
experience studying the frequency and function of neoantigen-specific T cells in preclinical 
models [66].  
Justification for Number of Patients and Specimens: Preliminary data from our phase I trial for 
mammaglobin-A DNA vaccine, though on patients with stable metastatic breast cancer, showed 
that the frequency of antigen-specific T cells can be measured with ~20% coefficient of 
variability (COV=SD/Mean). If assuming similar variability, the designed sample size (20 
patients in Arm A and 40 patients in Arm B) provides 80% power at 1-sided alpha = 0.2 to detect 
a minimum of 10% difference between the two treatment arms.  
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Collection of specimens 
Peripheral blood specimens will be collected pretreatment, after cycles 1, and 3 of therapy, and at 
the time of surgery as detailed in Section 5.4.4. The risks of venipuncture are minimal. 
For each subject six 10mL green-top (sodium heparin) tubes (BD Vacutainer, Catalog # 366480) 
will be collected at each time point.  
 
Handling of specimens 
If collected Monday through Thursday, ship tubes on day of collection at room temperature. 
If not shipped on day of collection, isolate and store PBMCs using the PBMC Isolation 
Procedure (see protocol below). 
Label each sample (tube or cryovial) with: 
• Study Number 
• Subject ID Number 
• Collection Date 
• Collection Time 
• PBMC volume in mL (for cryovials only) 
PBMC Isolation Procedure 
Collection 
1. 
Collect blood in specified heparin tube(s). 
Blood Separation 
1. 
Fractionate the whole blood by centrifuging at 400 X g for 25 min at room 
temperature on Ficoll with the brake off. This will separate the blood into an upper 
plasma layer, a lower red blood cell (RBC) layer, and a thin interface containing the 
peripheral blood mononuclear cells (PBMC) / buffy coat. Fractionate the blood as 
soon as possible after collection.  
2. 
Gently recover the buffy coat (PBMC) with a fresh disposable pipet, Pasteur pipet, or 
1000 ul micropipettor with a sterile tip. Try not to uptake the RBC layer below the 
buffy coat or plasma on top of the buffy coat. 
3. 
Place the recovered buffy coat into a 50mL centrifuge tube and fill up to 45mL using 
sterile Phosphate Buffered Saline (PBS), and centrifuge the PBMC at 400 X g.  
4. 
Resuspend the PBMC in PBS and count the cells.  
5. 
Proceed to section below, "Freezing collected cells." 
Freezing PBMC 
1. 
Wash the PBMC a second time. Resuspend the cell pellet at 107 cells/mL in freezing 
medium.  
2. 
Label cryovials (1.8mL) and record the total number of PBMC and number of vials.  
3. 
Transfer one mL cell suspension into each vial and leftover volume in the final vial. 
4. 
Transfer the cryovials into a control-rate freezing container and immediately store the 
container at -80°C. Allow samples to freeze at -80°C for a minimum of 8 hours 
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before transferring. 
5. 
Use the long forceps to take out the cryovial(s). 
 
Shipping of specimen(s) 
Please see Section 9.1.1.3 for general shipping information. PBMC samples will either be 
shipped at room temperature or with OCT blocks on dry ice.  
 
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10. 
STUDY CALENDAR 
Baseline evaluations are to be conducted within 1 week prior to start of protocol therapy. Scans and x-rays must be done ≤ 4 weeks 
prior to the start of therapy. In the event that the patient’s condition is deteriorating, laboratory evaluations should be repeated within 
48 hours prior to initiation of the next cycle of therapy. Patients receiving atezolizumab will be assessed for pulmonary signs and 
symptoms throughout the study.  There is a +/- 1 day window for all assessments detailed below. 
 
Pre-Study 
Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 Wk 9 Wk 10 Wk 11 Wk 12 Surgery10 
Off Study5 
Follow-up8 
Atezolizumab1 
 
A 
 
 
A 
 
 
A 
 
 
A 
 
 
 
 
 
Paclitaxel 
 
B 
B 
B 
B 
B 
B 
B 
B 
B 
B 
B 
B 
 
 
 
Carboplatin 
 
C 
 
 
C 
 
 
C 
 
 
C 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concurrent meds 
X 
X---------------------------------------------------------------------------------------------------X 
 
 
 
Physical exam 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
Vital signs 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
X 
 
X 
 
X 
 
X 
 
X 
 
 
X 
 
Performance status 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
CBC w/diff, plts 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
Serum chemistry2 
X 
X 
 
 
X 
 
 
X 
 
 
X 
 
 
 
X 
 
Coagulation panel7 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG (as indicated) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse event evaluation 
 
AE assessment will take place with every physician visit (Q3W). 
 
X 
 
Tumor measurements 
X 
Tumor measurements are repeated every 3-6 weeks. Documentation (radiologic) must be 
provided for patients removed from study for progressive disease. 
 
X 
 
Radiologic evaluation 
X 
Radiologic measurements should be performed at baseline and prior to surgery. 
 
X 
 
B-HCG 
X4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FFPE and fresh frozen tissue for TILs, PDL1 exp., 
immune sig., and neoantigen load9 
X 
 
 
X6 
 
 
 
 
 
 
 
 
 
X 
 
 
PBMCs for T cell response9 
X 
 
 
X6 
 
 
 
 
 
X 
 
 
 
X 
 
 
Record review for response and survival 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
A: 
Atezolizumab: Dose as assigned; Q3W x 4 doses; to be administered first (if randomized to Arm B) 
B:  Paclitaxel: Dose as assigned; QW x 12 doses; to be administered last (for all groups) 
C  
Carboplatin: Dose as assigned; Q3W x 4 doses; to be administered first (if randomized to Arm A) or second (if randomized to Arm B) 
1. 
ONLY if randomized to Arm B. 
2: 
Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, phosphorus, potassium, total protein, SGOT [AST], SGPT [ALT], sodium. 
3: 
Will take place after eligibility is confirmed. 
4: 
Serum pregnancy test (women of childbearing potential). 
5: 
Off-study evaluation for patients who come off treatment prior to surgery. 
6: 
Day 18-22.  
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7: 
INR, aPTT 
8: 
Follow up at 6 months and one year post-surgery will consist of routine monitoring and collection of data on response and survival. 
9: 
Refer to Section 9.0 for further information on correlative studies. 
10: 3-6 weeks after last dose of neoadjuvant chemotherapy. 
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11. 
MEASUREMENT OF EFFECT 
11.1 
Clinical response 
Physical examination: Within 14 days of registration and every 3 to 6 weeks after the start of 
neoadjuvant treatment (that is, at the end of either every cycle or every even-numbered cycle) the 
longest axis and the perpendicular axis of the measurable lesion should be measured and 
recorded in metric notation by tape, ruler or caliper technique on the case report forms.  
WHO criteria will be used to assess clinical response. 
Complete Response (CR) is defined as the disappearance of all known disease based on a 
comparison between the pre-treatment measurements and the measurements taken at the 
completion of neoadjuvant therapy. In addition there is no appearance of new lesions. 
Partial Response (PR) is defined as a 50% or greater decrease in the product of the bi-
dimensional measurements of the lesion (total tumor size) between the pre-treatment 
measurements and the measurements taken at the completion of neoadjuvant therapy. In addition 
there can be no appearance of new lesions or progression of any lesion. 
No Change (NC) occurs when a 50% decrease in total tumor size cannot be established nor has 
a 25% increase in the size of the lesion been demonstrated. 
Progressive Disease (PD) is defined as a 25% or greater increase in the total tumor size of the 
lesion from its pretreatment measurements or the appearance of new lesions.  
Treatment Resistance. A patient is said to have resistant disease if progressive disease is 
documented any time during neoadjuvant therapy. 
11.2 
Pathologic response 
A pathologic complete response (pCR) is defined as no histology evidence of invasive tumor 
cells in the surgical breast specimen and sentinel or axillary lymph nodes.  
All eligible women who have been treatment with combination therapy are included in the 
analysis of pCR. A patient is considered to not to have a pCR if any of the following are true: 
• There is histologic evidence of invasive tumor cells in the surgical breast specimen or the 
axillary lymph nodes. 
• The patient has discontinued neo-adjuvant treatment early due to refusal, toxicity, or 
radiographic or clinical evidence of progression and then goes straight to surgery where 
there is histologic evidence of invasive tumor cells in the surgical breast specimen and 
the axillary lymph nodes. 
• The patient has discontinued neo-adjuvant treatment early due to refusal, toxicity or 
radiographic or clinical evidence of progression and then receives alternative treatment. 
• The patient refuses surgery or is unable to undergo surgery due to a co-morbid condition. 
11.3 
Diagnosis of breast cancer recurrence and other cancer events  
11.3.1 
Local Recurrence  
Local recurrence is defined as histologic evidence of ductal carcinoma in situ or invasive breast 
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cancer in the ipsilateral breast or chest wall.  
11.3.2 
Regional recurrence 
Regional recurrence is defined as the cytologic or histologic evidence of disease in the ipsilateral 
internal mammary, ipsilateral supraclavicular, ipsilateral infraclavicular and/or ipsilateral axillary 
nodes or soft tissue of the ipsilateral axilla. 
11.3.3 
Distant recurrence 
Distant recurrence is defined as the cytologic, histologic, and/or radiographic evidence of disease 
in the skin, subcutaneous tissue, lymph nodes (other than local or regional metastasis), lung, 
bone narrow, central nervous system or histologic and/or radiographic evidence of skeletal or 
liver metastasis.  
11.3.4 
Second primary breast cancer  
Second primary breast cancer is defined histologic evidence of ductal carcinoma in situ or 
invasive breast cancer in the contralateral breast or chest wall.  
11.3.5 
Second primary cancer (non-breast) 
Any non-breast second primary cancer other than squamous or basal cell carcinoma of the skin, 
melanoma in situ, or carcinoma in situ of the cervix is to be reported and should be confirmed 
histologically whenever possible. 
11.3.6 
Death 
Underlying cause of death is to be reported. 
 
 
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12. 
STUDY OVERSIGHT AND DATA REPORTING/REGULATORY 
REQUIREMENTS 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
12.1 
Study oversight 
This protocol is monitored at several levels, as described in this section. The Protocol Principal 
Investigator is responsible for monitoring the conduct and progress of the clinical trial, including 
the ongoing review of accrual, patient-specific clinical and laboratory data, and routine and 
serious adverse events; reporting of expedited adverse events; and accumulation of reported 
adverse events from other trials testing the same drug(s). The Protocol Principal Investigator and 
statistician have access to the data at all times through the CTMS web-based reporting portal.  
The Protocol Principal Investigator will have, at a minimum, quarterly conference calls with the 
Study Investigators to review accrual, progress, and pharmacovigilance. 
All Study Investigators at participating sites who register/enroll patients on a given protocol are 
responsible for timely submission of data via Medidata Rave and timely reporting of adverse 
events for that particular study. This includes timely review of data collected on the electronic 
CRFs submitted via Medidata Rave. 
All studies are also reviewed in accordance with the enrolling institution’s data safety monitoring 
plan. 
12.2 
Data reporting 
Data collection for this study will be done exclusively through Medidata Rave. Access to the trial 
in Rave is granted through the iMedidata application to all persons with the appropriate roles 
assigned in the Regulatory Support System (RSS). To access Rave via iMedidata, the site user 
must have an active CTEP IAM account (https://eapps-ctep.nci.nih.gov/iam) and the appropriate 
Rave role (Rave CRA, Read-Only, or Site Investigator) on either the Corresponding 
Organization or Participating Organization roster at the enrolling site.  
Upon initial site registration approval for the study in RSS, all persons with Rave roles assigned 
on the appropriate roster will be sent a study invitation e-mail from iMedidata. To accept the 
invitation, site users must log into the Select Login (https://login.imedidata.com/selectlogin) 
using their CTEP-IAM user name and password, and click on the “accept” link in the upper 
right-corner of the iMedidata page. Please note, site users will not be able to access the study in 
Rave until all required Medidata and study specific trainings are completed. Trainings will be in 
the form of electronic learnings (eLearnings), and can be accessed by clicking on the link in the 
upper right pane of the iMedidata screen.  
Users that have not previously activated their iMedidata/Rave account at the time of initial site 
registration approval for the study in RSS will also receive a separate invitation from iMedidata 
to activate their account. Account activation instructions are located on the CTSU website, Rave 
tab under the Rave resource materials (Medidata Account Activation and Study Invitation 
Acceptance). Additional information on iMedidata/Rave is available on the CTSU members’ 
website under the Rave tab or by contacting the CTSU Help Desk at 1-888-823-5923 or by e-
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mail at ctsucontact@westat.com. 
12.2.1 
Method 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS). Data will be 
submitted to CTMS at least once every two weeks via Medidata Rave (or other modality if 
approved by CTEP). Information on CTMS reporting is available at: 
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11. On-site 
audits will be conducted on an 18-36 month basis as part of routine cancer center site visits. 
More frequent audits may be conducted if warranted by accrual or due to concerns regarding 
data quality or timely submission. For CTMS monitored studies, after users have activated their 
accounts, please contact the Theradex Help Desk at (609) 799-7580 or by email at 
CTMSSupport@theradex.com for additional support with Rave and completion of CRFs. 
12.2.2 
Responsibility for data submission 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all investigators at 
the ETCTN Sites understand the procedures for data submission for each ETCTN protocol and 
that protocol specified data are submitted accurately and in a timely manner to the CTMS via the 
electronic data capture system, Medidata Rave.  
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less than once 
every 2 weeks. The timeliness of data submissions and timeliness in resolving data queries will 
be tracked by CTMS. Metrics for timeliness will be followed and assessed on a quarterly basis. 
For the purpose of Institutional Performance Monitoring, data will be considered delinquent if it 
is greater than 4 weeks past due. 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing basis as 
data is received. Queries will be issued by CTMS directly within Rave. The queries will appear 
on the Task Summary Tab within Rave for the CRA at the ETCTN to resolve. Monthly web-
based reports are posted for review by the Drug Monitors in the IDB, CTEP. Onsite audits will 
be conducted by the CTMS to ensure compliance with regulatory requirements, GCP, and NCI 
policies and procedures with the overarching goal of ensuring the integrity of data generated 
from NCI-sponsored clinical trials, as described in the ETCTN Program Guidelines, which may 
be found on the CTEP 
(http://ctep.cancer.gov/protocolDevelopment/electronic applications/adverse events.htm) and 
CTSU websites. 
An End of Study CRF is to be completed by the PI, and is to include a summary of study 
endpoints not otherwise captured in the database, such as (for phase 1 trials) the recommended 
phase 2 dose (RP2D), and a description of any dose-limiting toxicities (DLTs). CTMS will 
utilize a core set of eCRFs that are Cancer Data Standards Registry and Repository (caDSR) 
compliant (http://cbiit.nci.nih.gov/ncip/biomedical-informatics-resources/interoperability-and-
semantics/metadata-and-models). Customized eCRFs will be included when appropriate to meet 
unique study requirements. The PI is encouraged to review the eCRFs, working closely with 
CTMS to ensure prospectively that all required items are appropriately captured in the eCRFs 
prior to study activation. CTMS will prepare the eCRFs with built-in edit checks to the extent 
possible to promote data integrity. 
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CDUS data submissions for ETCTN trials activated after March 1, 2014, will be carried out by 
the CTMS contractor, Theradex. CDUS submissions are performed by Theradex on a monthly 
basis. The trial’s lead institution is responsible for timely submission to CTMS via Rave, as 
above. 
Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). 
12.3 
CTEP multicenter guidelines 
N/A 
12.4 
Collaborative agreements language 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI 
under a Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical 
Company(ies) (hereinafter referred to as “Collaborator(s)”) and the NCI Division of Cancer 
Treatment and Diagnosis. Therefore, the following obligations/guidelines, in addition to the 
provisions in the “Intellectual Property Option to Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual property.htm) contained within the 
terms of award, apply to the use of the Agent(s) in this study: 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can Agent(s) 
be transferred or licensed to any party not participating in the clinical study. Collaborator(s) data 
for Agent(s) are confidential and proprietary to Collaborator(s) and shall be maintained as such 
by the investigators. The protocol documents for studies utilizing Agents contain confidential 
information and should not be shared or distributed without the permission of the NCI. If a copy 
of this protocol is requested by a patient or patient’s family member participating on the study, 
the individual should sign a confidentiality agreement. A suitable model agreement can be 
downloaded from: http://ctep.cancer.gov. 
2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other Agent(s), each the subject of different Collaborative Agreements, the access to and use 
of data by each Collaborator shall be as follows (data pertaining to such combination use shall 
hereinafter be referred to as "Multi-Party Data”): 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the proposed 
combination protocol, and the existence of any obligations that would tend to restrict NCI's 
participation in the proposed combination protocol. 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator to 
develop, obtain regulatory approval or commercialize its own Agent. 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must agree 
in writing prior to the commencement of the trials that it will use the Multi-Party Data solely 
for development, regulatory approval, and commercialization of its own Agent. 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
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will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm). 
Additionally, all Clinical Data and Results and Raw Data will be collected, used and disclosed 
consistent with all applicable federal statutes and regulations for the protection of human 
subjects, including, if applicable, the Standards for Privacy of Individually Identifiable Health 
Information set forth in 45 C.F.R. Part 164. 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a DMC 
for this clinical trial. 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-Cooperative 
Group studies for immediate delivery to Collaborator(s) for advisory review and comment prior 
to submission for publication. Collaborator(s) will have 30 days from the date of receipt for 
review. Collaborator shall have the right to request that publication be delayed for up to an 
additional 30 days in order to ensure that Collaborator’s confidential and proprietary data, in 
addition to Collaborator(s)’s intellectual property rights, are protected. Copies of abstracts must 
be provided to CTEP for forwarding to Collaborator(s) for courtesy review as soon as possible 
and preferably at least three (3) days prior to submission, but in any case, prior to presentation at 
the meeting or publication in the proceedings. Press releases and other media presentations must 
also be forwarded to CTEP prior to release. Copies of any manuscript, abstract and/or press 
release/ media presentation should be sent to: Email: ncicteppubs@mail.nih.gov. 
The Regulatory Affairs Branch will then distribute them to Collaborator(s). No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ 
proprietary information. 
12.5 
Genomic data sharing plan 
Data will be submitted no more than 6 months after the analytical dataset is finalized. Relevant 
phenotypic data, exposure data, and descriptive information will be shared, along with metadata 
necessary to reproduce published analyses. Specimen acquisition, experimental procedures, and 
data processing and analysis methods will be sent when data is submitted. Data will be available 
in dbGaP through both its unrestricted and controlled-access databases. Data will be made 
available for general research use. 
This genomic data sharing plan will be IRB-approved as part of this project. 
 
 
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13. 
STATISTICAL CONSIDERATIONS 
13.1 
Study design/primary objective 
TIL percentage and pathologic complete response (pCR) will be defined as the co-primary 
endpoints for this study. The primary objectives are to test the hypothesis that the combination of 
chemotherapy and atezolizumab will increase TIL percentage and pCR compared to 
chemotherapy alone in patients with newly diagnosed TNBC being treated with neoadjuvant 
chemotherapy. TIL percentage will be measured at baseline, and after initiation of therapy using 
a well validated histopathologic assay. The TIL percentage after initiation of therapy and pCR 
will be compared between patients receiving neoadjuvant chemotherapy alone (Arm A), and 
patients receiving neoadjuvant chemotherapy in combination with atezolizumab (Arm B). 
Patients will be randomized in a 1:2 ratio between Arm A (20 patients), chemotherapy alone, and 
Arm B chemotherapy plus atezolizumab (40 patients). Enrollment will continue until 60 
evaluable patients in both primary endpoints are enrolled or until 72 total patients are enrolled, 
whichever comes first.  Up to 72 patients will be enrolled to account for up to 20% of patients 
being non-evalubalbe for the primary endpoint(s).    
Data analysis will be performed following the modified intent-to-treat (ITT) principle, where 
patients who are randomized but are not evaluable for the primary endpoint will be excluded 
from the primary analysis. pCR-evaluable population includes all eligible women who have been 
randomized and received at least one dose of combination therapy, while  TIL-evaluable 
population includes all eligible women who have evaluable TIL percentage after one cycle of 
therapy (day 18-22). The balance of demographic and baseline clinical characteristics between 
two arms will be compared using t-test, Mann-Whitney rank-sum test, or Fisher’s exact as 
appropriate. The baseline and post-treatment TIL percentages between the two arms will be 
summarized using descriptive statistics at each time point. 
13.1.1 
Co-primary endpoint of TIL 
In the primary analysis, a mixed model will be used to compare TIL percentages after initiation 
of therapy (day 18-22) while adjusting for the potential effect of baseline TILs.  
,
G
*
T
*
 
G
*
 
T
*
 
ijk
k
j
3
k
2
j
1
0
ijk
δ
β
β
β
β
+
+
+
+
+
=
i
U
Y
 
where 
ijk
Y  is the TIL for ith subject measured at time j (j=1, 2 for baseline and 18-22 days post-
treatment, respectively) in the treatment group k (k=1, 2 for Arm A and Arm B, respectively). 
The parameter 𝛽𝛽0 denotes the overall intercept, while 𝛽𝛽1, 𝛽𝛽2, 𝑎𝑎𝑎𝑎𝑎𝑎 𝛽𝛽3 are the fixed effects for 
timing (T), treatment (G) and their interaction, respectively. 
i
U  and 
,
ijk
δ
represent the random 
intercept and measurement error respectively, both assuming to follow normal distributions and 
independent of each other, 
)
,0(
~
2
I
i
N
U
σ
 and 
)
,0
(
~
2
ijk
E
N
σ
δ
.  
The mixed model can account for the potential correlation among TILs measured in the same 
individual and can borrow information across different time points. The mixed model could 
therefore achieve more statistical power than a two-sample t-test. Data transformation will be 
performed if necessary to better satisfy the assumption of normality distribution. Based on two-
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sample t-test, n = 60 patients provides 80% power at 1-sided alpha = 0.1 to detect a minimum 
difference of 0.6*SD, where SD represents the measurement error of TIL. Based on an analysis 
of 314 TNBC, Denkert et al. found that the mean TIL percentage is 34.8% with a standard 
deviation of 24.7% (personal communication). If assuming similar variability in our study, the 
designed sample size allows 80% power to detect ~15% difference between arms. We expect this 
will be a clinically meaningful difference. Data from several phase III trials, have demonstrated 
that for every 10% increase in TIL percentage at baseline, there is a 15% to 20% increase in DFS 
and OS for TNBC patients [44-46]. Similar results have been obtained when evaluating the 
impact of TIL percentage after neoadjuvant chemotherapy [55-57]. Please note that we believe 
that an alpha = 0.10 is appropriate for these calculations, as in the context of a randomized phase 
2 trial, the study is designed to ensure that an inferior treatment would have low probability of 
being selected, rather than to ensure that the best treatment is definitely selected. Therefore, a 
large false positive error (alpha) is acceptable [98, 99]. 
Although the primary analysis will be performed following the ITT principle, those patients with 
missing TIL measurements after initiation of therapy (day 18-22) will be excluded. Every effort 
will be made to minimize the number of missing TIL measurements (see Section 9.1.1), and we 
expect that very few patients will have missing TIL measurements. However, we will cap the 
proportion of patients with missing TIL measurements that can be replaced at 20%, with a 
corresponding cap on the total accrual. To prevent missing TIL measurements from affecting 
study integrity, we will prospectively track missing data. 
Specifically, baseline demographic and clinical characteristics of randomized patients with and 
without missing TILs will be compared for evidence of selection bias. Missing data for each arm 
will be tabulated. If more than 5% of the randomized patients have missing TILs after initiation 
of therapy (day 18-22), a sensitivity analysis will also be performed using multiple imputation 
methods to fill in missing values and compare the difference between treatment arms. 
13.1.2 
Co-primary endpoint of pCR 
The co-primary objective is to test the hypothesis that the combination of chemotherapy and 
atezolizumab will increase the pathologic complete response rate compared to chemotherapy 
alone in patients with newly diagnosed TNBC being treated with neoadjuvant chemotherapy. We 
acknowledge that the study is powered for a correlative endpoint.  
Pathologic complete response rates will be summarized using contingency tables and compared 
using Chi-square test or Fisher’s exact test between patients receiving neoadjuvant chemotherapy 
alone (Arm A), and patients receiving neoadjuvant chemotherapy in combination with 
atezolizumab (Arm B). Pathologic complete response is defined as the absence of residual 
invasive or noninvasive tumor cells in breast and lymph nodes (ypT0 ypN0), consistent with the 
recommendations of the Cortazar meta-analysis [100], and the FDA Guidance for Industry 
document. 
The combination of carboplatin + docetaxel is actively being explored in the neoadjuvant setting 
for TNBC. Two early phase clinical trials have been reported [21-23]. The results of these 
studies have been very promising. 
We assume that a pCR rate of 40% or below will not warrant further investigation (null 
hypothesis).  A sample size of 60 patients (20 patients in Arm A, and 40 patients in Arm B) 
provides 80% power at 1-sided alpha = 0.10 to detect a minimum 29% improvement in 
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13.4.1 
Safety 
The incidence of toxicities by grade in each arm will be listed and 95% confidence intervals will 
also be calculated. The designed sample size allows us a reasonable precision to estimate the 
toxicity rate. Taking grade 4/5 toxicity as an example, if the “true” rate is 5% or less, there is 
<10% chance to observed 3 or more toxicities out of 20 patients. Conversely, if the true rate is 
15% or higher, then there is >95% chance to observe at least 1 toxicities out of 20 patients.  
13.4.2 Futility monitoring plan 
An interim analysis will be performed after the first 30 patients are evaluated for the primary 
endpoints.  The conditional power will be calculated for futility analysis based on the 
accumulated data. Conditional power is defined as the projected power to reject the null 
hypothesis at the end of the study given the data accrued up to the interim analysis. Therefore, a 
small value of conditional power indicates a highly likely, if not inevitable, conclusion of 
negative finding given the current data. If conditional power of 0.3 or less is obtained at the 
interim analysis for both TIL and pCR, enrollment will be suspended and the study investigators 
will consult with CTEP staff. A review of all available data will be performed, and a decision 
will be made with the input of CTEP staff as to whether to stop the trial for futility.  The 
untransformed data will be provided to CTEP and assessed to ensure that the stated primary 
endpoint will be measurable. The raw TILs data will be submitted for review of both the baseline 
distribution of the data and the assay performance and for potentially planning a post hoc 
analysis. 
13.4.3 
Safety stopping rule 
All grade 2 and 3 immunologic adverse events in addition to all grade 4 and 5 adverse events 
will be reviewed at each regularly scheduled study conference call. In the event of excessive 
adverse events thought to be possibly, probably, or definitely related to atezolizumab rather than 
standard of care chemotherapy (with excessive defined as grade 3 immunologic adverse events 
and any grade 4 or 5 events occurring in 3 of the first 20 patients), enrollment will be temporarily 
discontinued and all available data on adverse events will be assessed by a review committee in 
order to make a recommendation of continuation of accrual, suspension followed by formal 
amendment and reactivation, or study closure.  
13.5 
Analysis of exploratory endpoints 
Exploratory objective #1 is to evaluate potential biomarkers of response (as measured by pCR) to 
chemotherapy in combination with atezolizumab in patients with newly diagnosed TNBC. 
Potential biomarkers include baseline TIL percentage, baseline PD-L1 expression in the tumor 
and tumor infiltrating immune cells, baseline immune signature, and baseline neoantigen load. 
Univariate and multivariate logistic regression models will be used to evaluate predictive ability 
of these baseline biomarkers on the response to carboplatin-based chemotherapy in combination 
with atezolizumab therapy. Receiver operating characteristic (ROC) curves will be used to 
explore the optimal cut-off points for each biomarker to differentiated patients who achieve pCR 
versus those who do not. In the analysis of PD-L1 expression, the performance of existing cut-
off points (e.g., ≥ 1% and ≥ 5%) will also be assessed. To take full advantage of such a 
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randomized design, each model will also include the interaction term between treatment 
assignment and the baseline biomarker. This allows not only to answer the question whether the 
biomarker is predictive of pCR, but also whether the predictive ability is the same across two 
arms. We acknowledge that the study may not have adequate power to detect such interaction 
terms. The predictive ability will also be summarized using the area under ROC curves (AUC), 
and the 95% confidence intervals of AUC will be obtained using bootstrap resampling methods. 
Exploratory objective #2 is to evaluate the impact of chemotherapy in combination with 
atezolizumab on the immune response in patients with newly diagnosed TNBC. The immune 
signature and PD-L1 expression in the tumor and tumor-infiltrating immune cells will be 
evaluated at baseline, after initiation of therapy (day 18-22), and at the time of surgery. The 
temporal changes of immune signature and PD-L1 expression in each arm will be summarized 
using contingency tables or descriptive statistics (means, standard deviations, medians, etc.) as 
appropriate. The differences of temporal change between treatment groups (Arm A versus Arm 
B) or their association with clinical outcome (pCR vs. non-pCR) will also be assessed musing 
mixed model (PD-L1 expression) or generalized linear mixed model (immune signatures). 
Exploratory objective #3 is to evaluate the impact of chemotherapy in combination with 
atezolizumab on neoantigen-specific T cell responses in patients with newly diagnosed TNBC. 
The frequency and function of neoantigen-specific T cell across the two arms in the peripheral 
blood at each time point will be summarized using tools for high throughput analysis [98, 99]. 
The differences of temporal changes in neoantigen-specific T cell between treatment groups 
(Arm A versus Arm B) or their association with clinical outcome (pCR vs. non-pCR) will also be 
assessed using mixed models, followed by ad-hoc adjustment for multiple comparisons. 
Exploratory objective #4 is to evaluate the impact of chemotherapy in combination with 
atezolizumab on long-term clinical endpoints such as overall survival (OS) and disease-free 
survival (DFS) in patients with newly diagnosed TNBC. OS is defined as time from 
randomization to death due to any causes and these patients alive will be censored at the last 
clinical contact. DFS is defined as time from randomization to disease recurrence or death due to 
any causes, and patients alive and free of disease will be censored at the last clinical contact. The 
distribution of OS and DFS in the two treatment arms will be described using Kaplan-Meier 
product limit methods and compared by log-rank tests. Proportional hazard Cox models will be 
used to evaluate predictive ability of baseline biomarkers (as listed in the Exploratory objective 
#1) on OS and DFS. To take full advantage of such a randomized design, each model will also 
include the interaction term between treatment assignment and the baseline biomarker. We 
acknowledge that the study may not have adequate power to detect such interaction terms. The 
predictive ability will also be summarized using concordance statistics (C-index) whose 
interpretation is analogous to the area under ROC curves (AUC), and the 95% confidence 
intervals of C-index will be obtained using bootstrap resampling methods. 
13.6 
Reporting and exclusions 
13.6.1 
Evaluation of toxicity 
All patients will be evaluable for toxicity from the time of their first treatment with neoadjuvant 
chemotherapy. The incidences of toxicities across the two arms will be summarized using 
contingency tables and compared by 2-sample Chi-square test or Fisher’s exact test. 
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13.6.2 
Evaluation of response 
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations or if they are ineligible. Each patient will be assigned one of 
the following categories: 1) complete response, 2) partial response, 3) no change, 4) progressive 
disease, 5) treatment resistance, 6) early death from toxicity, 7) early death because of other 
cause, or 9) unknown (not assessable, insufficient data). [Note: By arbitrary convention, category 
9 usually designates the “unknown” status of any type of data in a clinical database.] In addition, 
pathologic response will be determined as described in Section 11.2. 
All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) should be included in the main analysis of the response rate. 
Patients in response categories 4-9 should be considered to have a treatment failure (disease 
progression). Thus, an incorrect treatment schedule or drug administration does not result in 
exclusion from the analysis of the response rate. Precise definitions for categories 4-9 will be 
protocol specific.  
All conclusions should be based on all eligible patients. Subanalyses may then be performed on 
the basis of a subset of patients, excluding those for whom major protocol deviations have been 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major 
protocol violations, etc.). However, these subanalyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the 
analysis should be clearly reported. The 95% confidence intervals should also be provided.  
13.6.3 
Evaluation of biomarkers 
Biomarker evaluable population includes all eligible women who have evaluable biomarkers 
after one cycle of therapy (day 18-22).    Four research core biopsies will be collected prior to 
treatment and after one cycle of therapy (day 18-22). At each time point, two cores will be 
placed in 10% buffered formalin and these will provide material for biomarkers. If no invasive 
cancer is present in either of the two FFPE cores at day 22, the sample will be considered 
inevaluable for biomarkers. Tumor tissues will also be obtained at the time of surgery, providing 
the third time point to measure TIL percentage. We expect that TIL percentage will be readily 
measured at baseline and at day 22, but evaluable TIL percentage may be difficult to measure at 
the time of surgery. We anticipate that the pCR may be 50%, or greater depending on the arm.  
 
 
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14. 
REFERENCES 
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Koplin LM, O'Connell TX: A new approach to the management of primary 
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NCI Protocol #: 10013 
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APPENDIX A 
PERFORMANCE STATUS CRITERIA 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time. 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities. Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated. Death not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 
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APPENDIX B 
PATIENT DRUG INFORMATION HANDOUT AND WALLET 
CARD  
 
Information for Patients, Their Caregivers, and Non-Study Healthcare Team on Possible 
Interactions with Other Drugs and Herbal Supplements  
 
The patient ______________________________________ is enrolled on a clinical trial using  
the experimental study drug, atezolizumab in combination with standard of care paclitaxel and 
carboplatin. This clinical trial is sponsored by the National Cancer Institute.  This form is 
addressed to the patient, but includes important information for others who care for this patient.  
 
These are the things that you as a healthcare provider need to know: 
 
Immunostimulatory agents, including but not limited to IFN-α, IFN-γ, anti-TNF-α, or IL-2 are 
prohibited during the study and for 10 weeks after the last dose of atezolizumab due to potential 
for increased risk of autoimmune conditions. Also to be avoided are immunosuppressive 
medications, including but not limited to cyclophosphamide, azathioprine, methotrexate, and 
thalidomide, which could potentially alter the activity and the safety of atezolizumab. 
Cytochrome P450 enzymes as well as conjugation/glucuronidation reactions are not involved in 
the metabolism of atezolizumab. No drug interaction studies for atezolizumab have been 
conducted. There are no known interactions with other medicinal products or other forms of 
interactions. However, ingredients for such  medicines have not been fully studied, and their use 
may result in unanticipated drug-drug interactions that may cause or confound assessment of 
toxicity. 
 
Initiation or increased dose of granulocyte colony stimulating factors (e.g., granulocyte colony 
stimulating factor, granulocyte/macrophage colony stimulating factor, and/or pegfilgrastim) 
should be discussed with the study’s principle investigator. 
  
Caution should also be exercised when paclitaxel is concomitantly administered with known 
substrates (e.g., repaglinide and rosiglitazone), inhibitors (e.g., gemfibrozil), and inducers (e.g., 
rifampin) of CYP2C8. 
 
Patients should also be advised to avoid traditional herbal or homeopathic or natural medicines 
 
To the patient: Take this paper with you to your medical appointments and keep the 
attached information card in your wallet.  
 
Atezolizumab may interact with other drugs which can cause side effects. For this reason, it is 
very important to tell your study doctors of any medicines you are taking before you enroll onto 
this clinical trial. It is also very important to tell your doctors if you stop taking any regular 
medicines, or if you start taking a new medicine while you take part in this study. When you talk 
about your current medications with your doctors, include medicine you buy without a 
prescription (over-the-counter remedy), or any herbal supplements such as St. John’s Wort. It is 
helpful to bring your medication bottles or an updated medication list with you. 
Many health care providers can write prescriptions. You must tell all of your health care 
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NCI Protocol #: 10013 
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112 
providers (doctors, physician assistants, nurse practitioners, pharmacists) you are taking part in a 
clinical trial.  
 
These are the things that you (the patient) and your prescribers need to know:  
 
Before you enroll onto the clinical trial, your study doctor will work with your regular health 
care providers to review any medicines and herbal supplements that might interact with the study 
drug.  
• 
Please be very careful! Over-the-counter drugs (including herbal supplements) may 
contain ingredients that could interact with your study drug. Speak to your doctors or 
pharmacist to determine if there could be any side effects.  
• 
Your regular health care provider should check a frequently updated medical reference or 
call your study doctor before prescribing any new medicine or discontinuing any 
medicine. Your study doctor’s name is _____________________________________  
and he or she can be contacted at _____________________________________.  
 
 
STUDY DRUG INFORMATION WALLET CARD 
You are enrolled on a clinical trial using the 
experimental study drug Atezolizumab. This clinical 
trial is sponsored by the NCI. Atezolizumab may 
interact with other drugs that you are taking. Because 
of this, it is very important to: 
Tell your doctors if you stop taking any medicines 
or if you start taking any new medicines. 
Tell all of your health care providers (doctors, 
physician assistants, nurse practitioners, or 
pharmacists) that you are taking part in a clinical trial. 
Check with your doctor or pharmacist whenever 
you need to use an over the counter medicine or 
herbal supplement. 
 
Before you enroll onto the clinical trial, your study doctor 
will work with your regular health care providers to review 
any medicines and herbal supplements that may interact 
with atezolizumab. 
Before prescribing new medicines, your regular health 
care providers should go to a frequently-updated medical 
reference for a list of drugs to avoid, or contact your study 
doctor.  
Your study doctor’s name is _______________________  
and he/she can be contacted at ____________ 
 
 
 
 
 
 
 
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