Preoperative Immune Checkpoint Inhibitor Therapy for Patients With Primary Untreated or Recurrent/Metastatic Squamous Cell Carcinoma of the Head and Neck (RM-SCCHN)
Phase: PHASE2
Conditions: Head and Neck Squamous Cell Carcinoma, Head and Neck Cancer, Head and Neck Cancer Metastatic
Sponsor: Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

Johns Hopkins Protocol #: 
J1923 
Page 1 of 70 
Preoperative Immune checkpoint inhibitor therapy for patients with primary untreated or 
recurrent/metastatic squamous cell carcinoma of the head and neck (RM-SCCHN)  
Acronym: 
 The SPARK study 
Johns Hopkins Protocol #: 
J1923 
BMS Protocol Number: 
CA209-9H7 
Center: 
Johns Hopkins University School of Medicine, 
Sidney Kimmel Comprehensive Cancer Center 
Principal Investigator:  
Tanguy Seiwert, MD     (Tanguy Seiwert) 
201 North Broadway, Room 8156 
Baltimore, MD 21287 
Telephone: 443-287-8312 
Fax:  410-614-9334 
e-mail: tseiwert@jhmi.edu
Surgical Investigator: 
Christine Gourin, MD 
JHOC Otolaryngology HNS 
601 North Caroline Street 
Baltimore, MD 21287 
Telephone: 443-287-2016 
Fax: 410-955-0035 
e-mail: cgourin@jhmi.edu
Biostatisticians: 
Hao Wang, MD 
Protocol Version Date, Number:  
Oct 27, 2017, Version 1.0 
March 16, 2018, Version 2.0 
June 19, 2018, Version 3.0 
August 8, 2018 Version 3.1 
September 7, 2018, Version 4 
April 16, 2019, Version 4.1 
July 29, 2019, Version 5.0 
August 18, 2020, Version 5.1 
December 15, 2020, Version 6.0 
November 11, 2021, Version 6.1 
June 01, 2022, Version 6.2 
NCT03878979

Johns Hopkins Protocol #: 
J1923  
 
Page 2 of 70 
 
Supported by:  
 
 
Bristol Myers Squibb 
 
Supplied Agents:  
Nivolumab (IND #) BMS Inc. 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 3 of 70 
 
Preoperative Immune checkpoint inhibitor therapy for patients with primary untreated or 
recurrent/metastatic squamous cell carcinoma of the head and neck (RM-SCCHN) ...... 1 
SUMMARY ............................................................................................................................. 5 
1. 
Endpoints ................................................................................................................... 6 
 
Primary Endpoint .................................................................................................... 6 
 
Secondary Endpoints .............................................................................................. 6 
2. 
BACKGROUND ............................................................................................................ 7 
 
Squamous cell carcinoma of head and neck (SCCHN) ............................................ 7 
 
Programmed death-1 – Preclinical and Clinical Studies ......................................... 8 
 
Rationale for immune checkpoint inhibitors in pre-operative treatment ........... 12 
 
Rationale for dosing and schedule........................................................................ 13 
3. 
PATIENT SELECTION .................................................................................................. 14 
 
Eligibility Criteria ................................................................................................... 14 
 
Exclusion Criteria................................................................................................... 16 
 
Inclusion of Women and Minorities ..................................................................... 18 
4. 
TREATMENT PLAN ..................................................................................................... 18 
 
Overall Study Design and Toxicity Assessment..................................................... 18 
 
Screening and pre-treatment criteria ................................................................... 19 
 
Study drug administration .................................................................................... 21 
 
Management of Nivolumab -related infusion reactions ...................................... 21 
 
Surgical resection .................................................................................................. 23 
 
Adjuvant treatment post surgery ......................................................................... 23 
 
Evaluation of peri-operative safety ...................................................................... 23 
 
Discontinuation, withdrawal and replacement of subjects .................................. 24 
 
Discontinuation of treatment ............................................................................... 24 
 
Study calendar ...................................................................................................... 25 
5. 
DOSE DELAY AND TOXICITY MONITORING ................................................................. 29 
 
Dose-Limiting Toxicity ........................................................................................... 29 
6. 
ADVERSE EVENTS ...................................................................................................... 30 
 
Serious Adverse Events ......................................................................................... 30 
 
Adverse Events ...................................................................................................... 32 
 
Nonserious Adverse Events .................................................................................. 32 
 
Laboratory Test Abnormalities ............................................................................. 33 
6.6  
Pregnancy .............................................................................................................. 34 
6.7  
Overdose ............................................................................................................... 34 
6.8   
Other Safety Considerations ................................................................................. 35 
6.9  
Adverse Event Attributions ................................................................................... 35 
6.10   Serious Adverse Event Reporting ......................................................................... 35 
6.11  Non-serious Adverse Event Collection and Reporting .......................................... 37 

Johns Hopkins Protocol #: 
J1923  
 
Page 4 of 70 
 
7. 
DATA AND SAFETY MONITORING .............................................................................. 37 
 
Data Management ................................................................................................ 37 
 
Safety Monitoring ................................................................................................. 38 
 
Ethical Considerations........................................................................................... 38 
8. 
PHARMACEUTICAL INFORMATION ............................................................................ 39 
 
Nivolumab ............................................................................................................. 39 
 
9. 
MEASUREMENT OF EFFECT ....................................................................................... 40 
 
Pathologic evaluation ........................................................................................... 40 
 
Radiographic evaluation ....................................................................................... 41 
 
Progression-Free Survival ..................................................................................... 46 
10. 
STATISTICAL CONSIDERATIONS ................................................................................. 46 
 
Study Design/Endpoints ........................................................................................ 46 
 
Sample Size, Analysis, and Accrual Rate ............................................................... 47 
 
Analysis of secondary endpoints .......................................................................... 50 
11. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ................................................... 50 
 
Collection of tumor tissue specimens ................................................................... 51 
 
Collection of blood samples .................................................................................. 52 
Appendix A. ECOG Performance Status Scale ........................................................................ 58 
Appendix B. Guidelines for Tissue Banking Process (may be modified based on guidelines in 
correlative SOP, which will be continually updated) .................................................. 59 
Appendix C. Immune-Related Adverse Events Management Algorithms ............................... 61 
Appendix D: Sociodemographic questionaires (Initial and follow-up) .................................... 62 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 5 of 70 
 
SUMMARY 
 
The primary objective of this study is to assess safety and feasibility of pre-operative nivolumab in 
patients with squamous cell carcinoma of head and neck (SCCHN) who will undergo surgery. The study 
will enroll a total of 26 patients and include patients with primary untreated, newly diagnosed SCCHN 
(Cohort 1), or patients with recurrent/metastatic SCCHN Cohort 2). Patients with primary untreated 
locoregional disease  will undergo surgical resection as originally planned, right after study treatment. 
Patients with recurrent/metastatic disease will also be enrolled ideally if disease can be resected, but 
distant metastatic disease is acceptable if an indication for surgery is clinically appropriate (e.g. for 
symptomatic control, or if a distant lesions is addressed separately (e.g. SBRT or resection, or with 
further palliative treatment). In such patients distant metastatic disease can be addressed at an 
interval with systemic therapy or other local therapy/ies (RT, metastectomy) as indicated.  All patients 
will be treated with 1 dose of nivolumab 480mg IV over 30 minutes 4-6 weeks prior to surgery.  
Subjects who sign the consent form but do not initiate protocol treatment for any reason (e.g., 
subjects who are screen failures), and patients who do not undergo surgical resection (for reasons 
unrelated to the study drug or toxicity) will be replaced and will not count towards the accrual goal. 
 
Overall study design 
 
 
 
The primary objective is to establish safety and feasibility of preoperative treatment with immune 
checkpoint inhibitor in patients with newly diagnosed or recurrent or metastatic SCCHN undergoing 
surgery.  
Secondary objectives are to 1) determine the pathologic response using immune related response 
criteria (irPRC)51, 2) determine the changes in tumor-specific T cell responses and tumor 
microenvironment  and compare these with baseline analyses in similar populations of patients 
undergoing resections without neoadjuvant therapy, 3) compare immunologic parameters between 
locoregional untreated and recurrent/metastatic sites, 4) compare irPRC51 with radiographic evidence 
of response to immunotherapy, and 5) determine progression free survival.  
 
Once patients are consented, they will be screened with pretreatment biopsy and images. They will 
receive 1 dose of nivolumab on Day -28 prior to planned surgery on or after Day 0 and up to/including 
Day +14. A 14 day window is allowable (as needed for scheduling purposes, or if clinically appropriate 
for patients with clinical benefit/improvement, if deemed safe by the treating physicians (surgeon & 
medical oncologist). Furthermore if clinically indicated patients may undergo surgery earlier (see 
Section 4.1.2 regarding early surgery, salvage treatment). 
  
Surgical specimens and blood will be collected for correlative analyses at various time points pre- and 
post-treatment.  
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 6 of 70 
 
1. Endpoints 
 
 
Primary Endpoint 
 
Safety and feasibility of neoadjuvant nivolumab administration in patients with newly diagnosed or  
locoregional recurrence or metastatic disease undergoing surgical resection, measured by 1) frequency 
of drug-related adverse events occurring up to 100 days after the last dose of nivolumab or 30 days 
after surgery (whichever is longer), and 2) successful completion of preoperative treatment and 
proceeding to surgery without any extended treatment related delays (defined as >28 days from 
preplanned Day 0)  from preplanned surgery date (Day 0) (or e.g. >14 days if surgery is on Day +14).  
 
 
 Secondary Endpoints 
 
1) Immune related pathologic response (irPRC)  
  irPRC criteria51 will be used – to assess resection specimen 
 
2) Major pathologic response (MPR)  
 
3) Progression free survival 
Progression-free survival will be measured from the time of start of neoadjuvant 
nivolumab until radiologic or clinical progression or death.   
 
4) Radiographic response rate 
Response will be determined by RECIST version 1.1. 
 
 
Exploratory 
 
1. To determine changes in expression of selected immune markers and responses compared 
to baseline, in the blood, primary tumor tissue and draining lymph nodes from patients 
receiving neoadjuvant therapy; to determine changes in the quality and quantity of tumor 
infiltrating lymphocytes; and to compare findings in tumor and draining lymph nodes from 
treated patients, to findings in a parallel stage-matched cohort of untreated patients on a 
companion tissue collection protocol 
 
2. To evaluate the potential effects of neoadjuvant therapy on normal head and neck mucosal 
tissue, by comparing tissues obtained on this study to those obtained from untreated 
patients undergoing tumor resection on a parallel tissue collection protocol. 
 
.  
 
3. To compare immunologic markers and responses in HPV+ vs HPV(-) tumors. This includes 

Johns Hopkins Protocol #: 
J1923  
 
Page 7 of 70 
 
responses to HPV16 E6 and E7 antigens in patients with HPV+ cancers. 
 
4. To explore features of the gut and oral microbiota of SCCHN patients before and after 
neoadjuvant nivolumab that may  correlate with pathologic response. 
 
5. To response to immunotherapy from pre- and on-treatment tissues in a histoculture model.  
 
6. To assess recurrence-free survival in patients receiving preoperative therapy in this study. 
 
7. To assess overall survival in high-risk patients with SCCHN receiving neoadjuvant therapy. 
 
8. To study response to metabolic and or immunotherapy from pre- and on-treatment tissues 
in functional models (histocultures (slices/explants) and short term (< 4 weeks) in-vitro 
organoids) with in-vitro antibody testing. 
 
9. To assess baseline immune and genomic tumor characteristics by performing multiplex 
immunofluorescence/immunochemistry (e.g., CD45, CD3, CD4, CD8, PDL1, etc.) and genetic 
sequencing (targeted and whole exome) on tissues slides/cryopreserved tissue blocks. 
 
 
 
 
 
 
 
 
 
 
2. BACKGROUND 
 
 
Squamous cell carcinoma of head and neck (SCCHN) 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 8 of 70 
 
SCCHN is the sixth most common cancer in the world, and approximately 50,000 new cases are 
diagnosed in a year in the United States1,2. SCCHN can arises from different sites in upper aerodigestive 
tract, which include oral cavity, oropharynx, hypopharynx and larynx. A subset of SCCHN is caused by 
human papillomavirus (HPV) and represents a biologically distinct process3,5. Expression of viral 
oncoproteins E6 and E7 result in rapid degradation of two important tumor suppressors, p53 and 
pRb6,8. Disruption in pRb function induces a compensatory increase in expression of p16INK4A (p16)9, 
which has been used as a surrogate marker for HPV in HNSCC occurring in the oropharynx 
(oropharyngeal SCC)10,11. HPV-related oropharyngeal SCC is associated with unique demographic 
characteristics such as male gender, better performance status, and lower consumption of tobacco 
and/or alcohol12. Additionally, survival for HPV-positive patients is higher than for HPV-negative SCCHN 
patients13, when treated with current standard of care, which is either surgery followed by adjuvant 
radiotherapy with or without concurrent chemotherapy or definitive concurrent 
chemoradiotherapy14,13,16,17.  HPV-negative SCCHN is typically associated with heavy use of tobacco and 
alcohol.15  
 
Although the majority of 
patients with SCCHN present 
with locally advanced disease, 
approximately 30-40% of 
patients develop recurrence 
even with  multimodality 
treatment16. For selected  
patients with locoregional 
recurrence, surgical salvage 
may be a viable therapeutic 
option17. Prospective cooperative 
group trial data suggests that 
surgical salvage for locoregional and distant failure in oropharyngeal SCC is independently associated 
with improved overall survival18 (Figure 1).  Furthermore in retrospective case series, this survival 
advantage of surgical salvage applies to both HPV-positive and negative patients, although the benefit 
in oligometastatic disease was largely limited to HPV-positive disease19. However, median disease free 
survival after salvage surgery remains poor for both HPV-positive and HPV-negative patients (1.28 year 
and 0.78 year, respectively)20. Combination chemotherapy such as platinum, fluorouracil and 
cetuximab (EXTREME regimen) does improve survival for RM-SCCHN21, but the absence of measurable 
disease burden precludes from the use of chemotherapy after salvage surgery as there is no 
measurable disease to serve as an endpoint to assess the response. Adjuvant radiotherapy or 
chemoradiotherapy can be performed for patients with locoregional recurrence after surgical salvage, 
but it is challenging and no survival benefit has been documented as most patients already had 
received radiotherapy or chemoradiotherapy as part of their initial treatment22.  
 
 
 Programmed death-1 – Preclinical and Clinical Studies 
 
Figure 1. Overall Survival after locoregional and distant recurrence by 
receipt of surgical salvage.  

Johns Hopkins Protocol #: 
J1923  
 
Page 9 of 70 
 
Programmed death-1 (PD-1 or CD279), primarily expressed on activated T cells, NK cells and B cells23 is 
a 55 kD type I transmembrane protein that is a member of the CD28 family of T-cell co-stimulatory/co-
inhibitory receptors that also includes CD28, CTLA-4, ICOS  BTLA and many others24. Two ligands 
specific for PD-1 have been identified: PD-L1 (also known as B7-H1 or CD274) and PD-L2 (also known as 
B7-DC or CD273)25-27. While PD-L1 can be expressed by many cell types, PD-L2 primarily expressed on 
antigen presenting cells, in particular dendritic cells. PD-L1 and PD-L2 have been shown to 
downregulate T-cell activation upon binding to PD-1 in both murine and human systems. PD-1 has 
been shown to inhibit CD28-mediated upregulation of IL-2, IL-10, IL-13, IFN-γ and Bcl-xL. PD-1 
expression has also been noted to inhibit T cell activation and expansion of previously activated cells. 
PD-1 contains an intracellular membrane proximal immunoreceptor tyrosine inhibitory motif (ITIM) 
and a membrane distal immunoreceptor tyrosine based switch motif (ITSM). Both Src homology region 
2 domain-containing phosphatase (SHP) -1 and -2 have been found to bind to the cytoplasmic tail of 
PD-1 and mediate its signaling. Once PD-1 is engaged by one of its ligands, SHP-1 and -2 bind to the 
phosphorylated tyrosine residue in the ITSM in its cytoplasmic region and mediate the suppressive 
effects of PD-1 via dephosphorylation of immunoreceptor tyrosine activating mitofs (ITAM) on TCR-
triggered signaling adaptors such as the zeta chain. As such, PD-1 engagement down-modulates 
antigen-specific T cell activation.  
 
Programmed death-1 – Preclinical Studies 
 
Further evidence for a negative regulatory role of PD-1 comes from studies of PD-1-deficient mice. PD-
1-deficient mice develop various autoimmune phenotypes later in life, including dilated 
cardiomyopathy, a lupus-like syndrome with arthritis and nephritis, and accelerated diabetes mellitus. 
The emergence of these autoimmune phenotypes is dependent upon the genetic background of the 
mouse strain and many of these phenotypes emerge at different times (almost always after 6 months 
of age) and show variable penetrance28,29. Thus PD-1 plays a more subtle regulatory role than CTLA-4, 
whose gene knockout results in lethal autoimmunity within 3-4 weeks of birth. In addition to the 
phenotypes of null mutations, PD-1 inhibition by antibody-mediated blockade in several murine 
models has been found to accelerate autoimmune diseases such as encephalomyelitis, graft-versus-
host disease, and type I diabetes in genetically prone mouse strains30,31. Taken together, these results 
suggest that PD-1 modulates immune responses in tissues undergoing inflammatory responses and PD-
1 blockade has the potential to enhance inflammatory (including “anti-self”) responses in tissue, but 
these responses are variable and dependent upon various host genetic factors. Thus, PD-1 deficiency 
or inhibition is not accompanied by a universal loss of tolerance to self-antigens. Preclinical animal 
models of tumors have shown that blockade of PD-1 by monoclonal antibodies (mAbs) can enhance 
the anti-tumor immune response and result in tumor rejection32. The effects of anti-PD-1 blockade in 
combination with vaccines and many other immunomodulatory agents  have been tested in multiple 
murine tumor models. 
 
 Clinical development of anti-PD-1 antibodies 
 
Nivolumab (BMS-936558, ONO-5438, MDX-1106) is a fully human, IgG4 (kappa) monoclonal antibody 

Johns Hopkins Protocol #: 
J1923  
 
Page 10 of 70 
 
that binds PD-1 with high affinity blocking its interactions with its ligands PD-L1 (B7- H1) and PD-L2 (B7-
DC) and increasing tumor antigen specific T cell proliferation and cytokine secretion33. Nivolumab has 
been approved by FDA for melanoma, renal cell carcinoma (RCC), non-small cell lung cancer (NSCLC), 
SCCHN, bladder cancers, gastric cancer, hepatocellular cancer, MSIhigh colon cancer and classical 
Hodgkin’s lymphoma as single agent and for melanoma in combination with ipilimumab.  
A phase 1 single dose, dose-escalation study of nivolumab in 39 heavily pretreated patients with solid 
tumors (CA209-001, NCT00441337) demonstrated good tolerance and signals of efficacy33. Patients 
with advanced NSCLC, melanoma, RCC, metastatic castration-resistant prostate cancer (mCRPC) and 
metastatic colorectal cancer (CRC) in this study received a single IV infusion of nivolumab over 1 hour 
in escalating cohorts of 0.3, 1, 3 or 10 mg/kg. Restaging was performed radiologically at 8 and 12 
weeks, and patients with no adverse event (AE) ≥3 and stable disease or response by RECIST received 
additional doses of nivolumab at weeks 12 and 16 followed by further restaging at 3 months. Those 
with continued clinical benefit could receive two more doses, spaced by 4 weeks. Treatment could 
continue for up to 2 years. 
Nivolumab was in general well-tolerated with most frequent adverse events being hematologic 
(notably a grade 3 reduction in CD4 count in 17.9% of patients), fatigue and mild musculoskeletal 
symptoms. A maximum tolerated-dose (MTD) was not reached.  
Immune-related colitis, well described with CTLA-4 inhibition, occurred in 1 patient and resolved with 
treatment with infliximab and steroids. Grade 2 hypothyroidism and grade 2 polyarthritis were noted 
in 1 and 2 patients respectively. Efficacy was promising with a durable complete response (CR) in a CRC 
patient, 2 partial responses (PRs) in RCC and melanoma patients, and a transient response not meeting 
PR criteria in a NSCLC patient. PD-L1 (B7-H1) expression was assessed by immunohistochemistry in 
pretreatment tumor specimens from 9 patients. Of these, 3 of 4 patients with membranous (cell 
surface) tumor cell expression of PD-L1 experienced tumor regression; none of 5 patients without 
expression of PD-L1 experienced a tumor response, suggesting a marker for further investigation. 
Pharmacodynamic analyses suggested that high level occupancy of the PD-1 receptor on circulating T 
cells persisted for up to 85 days after a single dose of nivolumab. 
Subsequent to this original study, antibodies targeted to PD-1 or PD-L1 that block this ligand-receptor 
interaction have been tested extensively in most human cancers34, 36. Clinical responses have been 
seen in a variety of cancers, many of which are extremely durable. Immunologic studies support the 
notion that clinical responses are due to “unleashing” of endogenous anti-tumor T cells from PD-1 
pathway restraint. Virtually all side-effects of these antibodies are immune-related (autoimmune or 
hyperimmune), with 9-15% grade 3/4 drug-related adverse events. As of 2017, two anti-PD-1 
antibodies (nivolumab, pembrolizumab) and three anti-PD-L1 antibodies (durvalumab, atezolizumab, 
avelumab) have been approved for various cancers including melanoma, renal cancer, NSCLC, 
hepatocellular cancer, Merkel Cell cancer, HNSCC, bladder cancer, gastric cancer, Hodgkin lymphoma 
and mismatch repair deficient cancers of all types. Clinical responses are higher in patients with 
increased PD-L1 expression in their cancer and in cancers with high mutational load. Expression of viral 
antigens in virus-associated cancers (MCPyV in Merkel Cell, HPV in some HNSCC and EBV in some 

Johns Hopkins Protocol #: 
J1923  
 
Page 11 of 70 
 
Hodgkin lymphomas) are thought to generate tumor-specific antigens that can be targeted by T cells. 
There have been over 2000 clinical trials, completed or ongoing, testing PD-1 pathway blocking 
antibodies either alone or in combination with other agents. While initial trials tested these antibodies 
in refractory metastatic cancer, success in the adjuvant and neoadjuvant setting has prompted the 
therapeutic blockade of the PD-1 pathway much earlier in the course of disease.    
 
Further information on nivolumab is available in the current version or the investigator’s brochure  
  Immune checkpoint inhibitors in SCCHN 
 
SCCHN has been associated with dysregulation and evasion of the immune system. It has been 
described as an immunosuppressive disease, with lower absolute lymphocyte counts than those found 
in healthy subjects, impaired natural killer (NK) –cell activity, and poor antigen-presenting function. 
Impairment of tumor-infiltrating T lymphocytes has also been reported in SCCHN and other cancers, 
with a strong impact on clinical outcome. In addition, suppressive regulatory T cells (Tregs) have been 
linked to SCCHN tumor progression37. 
 
Immune checkpoint inhibitors offer promise as a novel therapeutic approach for RM-SCCHN. 
Especially, anti-PD-1 antibodies have shown notable response rates in heavily pre-treated RM-SCCHN 
patients38 and also showed a significant survival benefit compared to conventional chemotherapy in 
platinum refractory patients. Keynote-012 was a phase 1b study of pembrolizumab in SCCHN patients 
with recurrent/metastatic SCCHN.  192 patients were treated at two different dose levels; in the 
combined analysis the response rate was 18% and OS at 12 months was 38%39. A single arm phase II 
study of pembrolizumab, an anti-PD1 antibody, in SCCHN patients who had failed platinum and 
cetuximab, pembrolizumab showed robust overall response rate of 18%40. These data led to approval 
of this agent in platinum refractory RM-SCCHN patients.  
 
In a large randomized double blinded phase III clinical trial, 
nivolumab, another anti-PD1 antibody, almost doubled 1-
year overall survival37 (Figure 2) and was approved for RM-
SCCHN as well. Both of these agenets are approved without 
a companion biomarker for patient selection.  Given these 
successes of immune checkpoint inhibitors in RM-SCCHN, 
there is enthusiasm to bring these agents in earlier stage of 
SCCHN. Pembrolizumab alone or in combination with 
chemotherapy is being compared with combination of 
chemotherapy and cetuximab in treatment naïve RM-SCCHN 
patients (NCT02252042), and nivolumab is being compared 
with combination of nivolumab and ipilimumab in a 
randomized phase 2 trial in platinum eligible RM-SCCHN 
patients (NCT02823574). An anti-PD-L1 antibody, 
durvalumab, is being tested against durvalumab in 
Figure 2. Nivolumab improves overall survival in 
RM-SCCHN patients. 

Johns Hopkins Protocol #: 
J1923  
 
Page 12 of 70 
 
combination with tremelimumab (anti-CTLA4 antibody) and standard of care chemotherapy 
(NCT02551159). Even in locally advanced disease, anti-PD1 therapy is being widely adopted in various 
clinical setting, in combination with radiotherapy or surgery. For example, nivolumab is being 
incorporated with definitive radiotherapy or chemoradiotherapy in locally advanced SCCHN patients 
(NCT02764593), and pembrolizumab was successfully administered without significant delay for 
patients undergoing definitive surgical management for locally advanced SCCHN41. Based on these 
studies, it is timely and reasonable to ask whether immune checkpoint inhibitors could be incorporated 
in treatment of patients with primary untreated locally advanced disease, or recurrent and/or 
metastatic RM-SCCHN who are undergoing surgical salvage. Currently there are no prospectively 
validated biomarkers to assist with identifying patients who are at higher chance of obtaining a 
response to PD-1 inhibitors.  Thus, there is a need to further understand characteristics of tumors that 
will respond in the newly diagnosed and locally advanced setting.   
 
 
  Rationale for immune checkpoint inhibitors in pre-operative treatment 
 
Immune checkpoint inhibitor therapy has shown to have activity in RM-SCCHN42. In addition,  immune 
checkpoint inhibitors have been shown to be a very effective treatment in non-small cell lung cancers 
(NSCLC)43, including squamous cell carcinoma of lung, which shares biologic characteristics with HPV 
negative SCCHN44. A neoadjuvant nivolumab study demonstrated the safety of pre-operative immune 
checkpoint inhibitors in resectable NSCLC and has shown that 2 doses of nivolumab could be safely 
administered without significant delay in surgery.  
 
Adults with untreated surgically resectable stage I-IIIA NSCLC received two doses of nivolumab (anti-
PD-1) preoperatively. The primary endpoints of the study were safety and feasibility. Tumor pathologic 
response, PD-L1 expression, mutation burden and mutation-associated neoantigen-specific T-cell 
responses were evaluated. Neoadjuvant nivolumab had an acceptable side effect profile without 
surgical delays, and 20 of 21 tumors were completely resected. Major pathologic response occurred in 
45% (9/20) of resected tumors. Responses occurred in both PD-L1 positive and negative tumors. 
Multispectral imaging demonstrated robust influx of PD-1+ CD8+ T cells in resected tumors. Pathologic 
response significantly correlated with pre-treatment tumor somatic mutation burden. T cell clones 
shared between the tumor and peripheral blood increased systemically upon anti-PD-1 treatment in 8 
of 9 patients analyzed. Mutation-associated neoantigen-specific T-cell clones, from a primary tumor 
that underwent pathologic complete response, rapidly expanded in peripheral blood at 2-4 weeks 
post-treatment, some of these clones were not detected before anti-PD-1. These findings underpin 
multiple neoadjuvant trials of anti-PD-1 and anti-PD-L1-based immunotherapies. 
 
 Neoadjuvant PD-1 blockade in SCCHN 
 
To date, two studies have reported preliminary experiences with neoadjuvant treatment for newly 
diagnosed squamous cell carcinoma of the head and neck.  Dr. Uppaluri and colleagues treated 21 
patients with 1 dose of pembrolizumab after surgical resection.  A pathologic response was noted in 
43% of patients and after 1 year none of the first 10 patients had a locoregional or distant metastatic 

Johns Hopkins Protocol #: 
J1923  
 
Page 13 of 70 
 
disease recurrence45.  Another study, 29 patients (12 HPV+, 17 HPV-) received two doses of nivolumab 
followed by surgical resection.   Treatment was able to be administred without protocol specified 
delays in surgery. In addition, 48% of evaluable patients experiences pre-surgical tumor reduction46. 
Neither of these studies reported any analysis of genomic landscape of the tumor, T cell responses to 
either HPV antigens or neoantigens, nor was there any detailed analysis of the tumor immune 
microenvironment in response to neoadjuvant PD-1 blockade.  
 
Both of these reports demonstrate early data regarding the feasibility and treatment related impact of 
neoadjuvant PD-1 inhibitor therapy in previously untreated patients with SCCHN.  To date, there is no 
data on the feasibility of neoadjuvant therapy among patients with recurrent disease.  These patients 
are often at higher risk of surgical complications related to prior treatment related morbidity.  In 
addition, it is unclear what the expected pathologic response to PD-1 inhibitors would be in a prior 
treated population.   
 
In addition, there is a great need in SCCHN to further understand which patients are likely to respond 
to PD-1 inhibitors.  In our study, we hope to provide further data on the feasibility of neoadjuvant 
therapy in the untreated and recurrent population of SCCHN.  We also seek to obtain greated clarity on 
the immune response in both populations with focus on PD-L1 expression, mutation burden and 
mutation-associated neoantigen-specific T-cell responses. The rationale of studying both previously 
untreated and recurrent populations is to obtain a greater understanding or PD-inhibitor activity and 
to compare the T cell responses in both groups.   
 
 
Rationale for dosing and schedule 
 
The planned schedule of a preoperative dose of nivolumab, flat dose 480 mg, given once 28 days prior 
to surgery (with an additional 14 day window). The rationale for flat dosing is noted below. The 
duration of preoperative treatment of approximately 28 days was initially chosen as a short time 
period is unlikely to allow significant progression of disease which might preclude complete surgical 
resection.  However, a 14 day window is allowable (as needed for scheduling purposes, or if clinically 
appropriate for patients with clinical benefit/improvement, if deemed safe by the treating physicians 
(surgeon & medical oncologist). Furthermore if clinically indicated patients may undergo surgery 
earlier (see Section 4.1.2 regarding early surgery, salvage treatment). 
Waiting 28-42 days after dosing before surgery would still allow for time to appreciate immune 
mediated cellular changes. 
 
Flat (standardized) dosing of nivolumab as a single agent: 
 
Nivolumab monotherapy has been extensively studied in a number of tumor types including NSCLC, 
MEL, RCC, and CRC with body weight normalized dosing (mg/kg). Nivolumab pharmacokinetics (PK) 
and exposures of subjects in these studies have been characterized by population pharmacokinetic 
(PPK) analysis of data collected in these studies, together with PK data from several phase 1, 2, and 3 
clinical studies of nivolumab monotherapy in solid tumors. Population PK (PPK) analyses have shown 

Johns Hopkins Protocol #: 
J1923  
 
Page 14 of 70 
 
that the PK of nivolumab are linear, with dose proportional exposures over a dose range of 0.1 mg/kg 
to 10 mg/kg, and are similar across tumor types. Nivolumab clearance and volume of distribution were 
found to increase with increasing body weight, but the increase was less than proportional, indicating 
that a mg/kg dose represents an over-adjustment for the effect of body weight on nivolumab PK. Given 
the relationship between nivolumab PK and body weight, a flat dose is expected to lead to lower 
exposures in heavier patients, relative to the exposures in lighter patients.  
 
Using the PPK model, nivolumab steady-state trough, peak and time-averaged concentration (Cminss, 
Cmaxss, and Cavgss, respectively) were predicted for a flat nivolumab dose of 240 mg Q2W and 
compared to those following administration of 3 mg/kg Q2W in NSCLC subjects. A dose of 240 mg 
nivolumab is identical to a dose of 3 mg/kg for subjects weighing 80 kg, which is the approximate 
median body weight of NSCLC subjects in the 3 Phase 2 and 3 BMS clinical studies of nivolumab 
monotherapy. The geometric mean values of Cminss, Cmaxss, and Cavgss with flat dosing are slightly (< 
15%) higher than that produced by a 3 mg/kg dose, and the coefficient of variation (cv%) in these 
measures of exposure are only slightly (< 10%) greater than that of 3 mg/kg dosing. 
 
Across the various tumor types in the BMS clinical program, nivolumab has been shown to be be safe 
and well tolerated up to a dose level of 10 mg/kg, and the relationship between nivolumab exposure 
produced by 3 mg/kg and efficacy has been found to be relatively flat. Taken together, the PK, safety, 
and efficacy data indicate that the safety and efficacy profile of 240 mg nivolumab will be similar to 
that of 3 mg/kg nivolumab.  Receptor occupancy studies now support a dose of 480mg IV every 4 
weeks, which is thought to be equivalent to the 240mg IV every 2 week schedule. This flat dose 
maintains saturation receptor occupancy for greater than 4 weeks. Thus a single flat dose of 480 mg 
given 4 weeks prior to resection is recommended. 
 
 
3. PATIENT SELECTION 
 
 
Eligibility Criteria  
 
Cohort 1: Subjects must have histologically confirmed previously untreated squamous cell carcinoma 
of the head and neck that is amenable to surgical resection as part of standard of care. 
 
Cohort 2: Subjects must have histologically confirmed recurrent squamous cell carcinoma of head and 
neck, that is amenable for salvage surgery.  Sites of recurrence may either be locoregional and/or 
distant. Distant metastatic disease is permissible in this cohort and can be addressed at an interval 
with systemic therapy (e.g. chemotherapy, targeted therapies), or local therapies (e.g. radiation, 
metastatectomy) as clinically indicated.  
 
Distribution between both patient cohorts is aimed to be 1:1 but may vary. 
 
For both cohorts:  

Johns Hopkins Protocol #: 
J1923  
 
Page 15 of 70 
 
 
 The primary site should be a head and neck squamous cell carcinoma (including, 
but not limited to oral cavity, oropharynx, hypopharynx, or larynx, paranasal 
sinuses, nasal cavity). Squamous cell carcinoma of unknown primary, diagnosed 
in lymph nodes in neck, can be included but should be tested for p16 and 
confirmed with an HPV specifc assay (testing NOT required for enrollment; can 
be done at an interval).  
 
 Subjects with oropharyngeal primary tumors must have confirmation of HPV 
tumor status per clinical standards, although not necessary at enrollment.  
 
3.1.3 
Subjects must have been determined to be candidates for surgical resection by a 
multidisciplinary team including a surgeon, a medical oncologist and a radiation 
oncologist.  
 
3.1.4 Subjects must have at least one lesion that can be (or has been) biopsied at 
baseline. 
 
3.1.5 Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1 (see 
Appendix A for definitions). 
 
3.1.6 Age >18 years.   
 
3.1.7 Life expectancy of greater than 6 months. 
 
3.1.8 Patients must have normal organ and marrow function as defined below: 
 
leukocytes 
≥ 1,500/mcL 
absolute neutrophil count 
≥ 1,000/mcL 
platelets 
≥ 100,000/mcL 
total bilirubin  
≤ 1.5 X institutional upper limit of normal 
(except subjects with Gilbert syndrome, who 
can have total bilirubin < 3.0 mg/dL) 
AST(SGOT)/ALT(SGPT) 
≤ 3 X institutional upper limit of normal 
Creatinine 
OR 
creatinine clearance 
within normal institutional limits 
OR 
≥ 40 mL/min (using modified Cockcroft-Gault 
formula) for patients with creatinine levels 
above institutional normal. 
 
3.1.9 The effects of nivolumab on the developing human fetus are unknown.   
1) Women of childbearing potential (WOCBP) must have a negative urine or 

Johns Hopkins Protocol #: 
J1923  
 
Page 16 of 70 
 
serum pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) 
within 24 hours prior to the start of study treatment. 
2) Women must not be breastfeeding 
3) Women of childbearing potential (WOCBP) must agree to follow instructions 
for method(s) of contraception for the duration of treatment with study 
treatment and for 5 months post-treatment completion. Women should use an 
adequate method(s) of contraception (Refer to nivolumab IB for WOCBP and 
methods of contraception to be provided). 
4) Males who are sexually active with WOCBP must agree to follow 
instructionsfor method(s) of contraception  for the duration of treatment with 
study treatment(s) and 7 months post-treatment completion. In addition, male 
participants must be willing to refrain from sperm donation during this time. 
Men who are sexually active with WOCBP must agree to follow instructions for 
method(s) of contraception. 
 
3.1.10 Patient understands the study regimen, 
its requirements, risks and discomforts and is able and willing to sign the informed 
consent form. Voluntary signed and dated IRB/IEC approved written informed 
consent form in accordance with regulatory and institutional guidelines must be 
obtained before the performance of any protocol related procedures that are not 
part of normal patient care. Subjects must be competent to report AEs, understand 
the drug dosing schedule and use of medications to control AEs. 
 
3.1.11 Measurable disease – either radiologically (per RECIST V 1.1) or clinically 
measurable on exam in order to assess treatment response. 
 
 Exclusion Criteria 
 
 Any active history of a known autoimmune disease.  Subjects with vitiligo, type 1 
diabetes mellitus, residual hypothyroidism requiring hormone replacement, or 
conditions not expected to recur in the absence of an external trigger are 
permitted to enroll. 
 
 Patients who have had prior chemotherapy for newly diagnosed (cohort 1) or 
recurrent (cohort 2) head and neck cancer. In cohort 2 only, previous 
perioperative chemotherapy or chemoradiation for the management of localized 
or locally advanced disease is permitted.   
 
 Patients who received prior therapy with anti-PD-1, anti-PD-L1, anti-PD-L2, anti 
CD137, anti-CTLA-4 antibody therapies, any other antibody or drug specifically 

Johns Hopkins Protocol #: 
J1923  
 
Page 17 of 70 
 
targeting T-cell co-stimulation or checkpoint pathways.   
 
 Any live / attenuated vaccine (e.g. varicella, zoster, yellow fever, rotavirus, oral 
polio and measles, mumps, rubella (MMR) etc.) within 30 days of first treatment. 
 
 Patients with uncontrolled brain metastases 
 
Patients with brain metastases must have stable neurologic status following local 
therapy (surgery and/or radiation) for at least 2 weeks without the use of 
steroids or on stable or decreasing dose of ≤ 10mg daily prednisone (or 
equivalent), and must be without neurologic dysfunction that would confound 
the evaluation of neurologic and other adverse events.  Patients with a history of 
carcinomatous meningitis are not eligible. 
 
 Patients who have an active concurrent malignancy that is not controlled/cured 
and could impact life expectancy within the next 3 years. E.g. patients with 
localized cutaneous squamous cell carcinoma or basal cell carcinoma or treated 
prostate cancer with no evidence of disease progression  may be allowed to 
enroll after review by the study team and principal investigator. 
 
 Uncontrolled inter-current illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, 
uncontrolled cardiac arrhythmia, myocardial infarction or new onset angina 
within six months of enrollment, or psychiatric illness/social situations that 
would limit compliance with study requirements. 
 
 Women who are pregnant or nursing.  
 
 Men with female partners who are not willing to use contraception. 
 
 Active infection with hepatitis B or hepatitis C (active infection is defined by 
abnormal liver function tests (=elevated AST/ALT) or ongoing use of an antiviral 
hepatitis treatment). Patients with normal liver function tests (defined by 
normal AST/ALT) per definition do not have an active infection and are eligible to 
enroll without additional testing).  
 
 Patients with a condition requiring systemic treatment with either 
corticosteroids (>10 mg daily prednisone equivalent) or other 
immunosuppressive medications within 14 days of randomization.  However, 
inhaled or topical steroids and adrenal replacement steroid doses < 10 mg daily 
prednisone equivalent, are permitted in the absence of active autoimmune 

Johns Hopkins Protocol #: 
J1923  
 
Page 18 of 70 
 
disease. 
 
 EBV(+) head and neck cancer (e.g. EBV(+) nasopharyngeal carcinoma) 
 
 Patient with HIV are excluded given the unknown risk of interaction with HAART 
and the unknown benefit of immunotherapy in this population. 
 
               
 
 
 
 
Inclusion of Women and Minorities 
 
Both men and women of all races and ethnic groups are eligible for this trial. 
 
 
4. TREATMENT PLAN 
 
 
 Overall Study Design and Toxicity Assessment 
 
The study will acrrue to 2 cohorts, each of which consists of 12 patients who undergo surgical 
resection. Total of 26 patients will be accrued to the study. Patients who do not undergo surgery for 
reasons unrelated to toxicity of the study treatment will be replaced and will not count toward the 
accrual goal of 12 surgically resected patients in each cohort. If enrollment on 1 cohort is significantly 
faster, the lesser enrolling cohort number of patients may be decreased in favor of the better enrolling 
cohort to keep the total number of evaluable patients at 26 pts (also see statistical section). 
 
 Treatment overview (Cohorts 1 & 2) 
 
After being consented, patients will undergo baseline evaluations including clinical exam, complete 
blood count, blood chemistry, and thyroid function test.  Baseline core or surgical biopsy and images 
with either CT scan or MRI scan will be obtained at screening. Blood collection for correlative analyses 
will be performed anytime after consent and prior to Nivolumab administration.  Nivolumab 480mg 
will be administered intravenously on approximately Day -28 prior to planned surgery on Day 0 to Day 
+14 (14  day window as needed for scheduling surgery/logistics). An earlier surgery date is permissible 
if clinically indicated – see section 4.1.2 (salvage treatment). 
 
Patients will undergo post-treatment images and specimen collection ideally within 7 days from 
planned surgery date, or as clinically indicated. 
 
Post-operative adjuvant treatment with radiotherapy or chemoradiotherapy can be delivered, if 
clinically indicated at the discretion of treating physician following the standard of care. All subjects will 

Johns Hopkins Protocol #: 
J1923  
 
Page 19 of 70 
 
get follow up imaging about 3 months after completion of curative therapy (e.g. after adjuvant 
therapy) as per clinical routine.  
 
After the initial post-treatment images, further imaging will be obtained as clinically indicated. In case 
of recurrence, a biopsy will be obtained and the specimen will be secured for future analyses if 
clinically feasible. 
 
To explore oral and gut microbial correlates of response to neoadjuvant nivolumab,  stool samples and 
oral rinses will be collected at baseline prior to infusion and then again prior to surgery.  Subjects will 
also be asked to fill out a medical, antibiotic use and dietary questionnaire that will be used to assess 
whether antibiotic use or dietary patterns correlate with features of the oral and gut microbiome.  
 
  Early salvage treatment options: salvage surgery, salvage chemotherapy 
 
In patients with clinically worsening disease, or concern that resectability may be at risk, or due to 
extenuating scheduling circumstances,  an earlier surgery date can be approved in consultation with the 
treating surgeon, medical oncologist, and study team.  
 
Alternatively, neoadjuvant chemotherapy can be given in patients with clinically worsening disease, or 
concern that resectability may be at risk after approval and review by the treating surgeon, and medical 
oncologist, and study team.  
 
Such ‘salvage’ patients will continue on study, unless deemed non-evaluable for other reasons. 
 
 
Screening and pre-treatment criteria 
 
 Recruitment 
 
Patients will be recruited through the head and neck oncology clinic at Sidney Kimmel Comprehensive 
Cancer Center at Johns Hopkins (SKCCC) including medical oncology, radiation oncology, 
multidisciplinary, dental/ oral surgery and head and neck surgical oncology. Each enrolled subject will 
be assigned a participant sequential subject number at the time of consent with site number assigned 
in advance, e.g., 1-001, 1-002, etc. 
 
 Determination of Eligibility 
 
After eligibility is established, the study staff will register participants. The following are required to be 
submitted for successful registration: 
 
 Copy of subject consent 
 Copies of the following documents: 
o Diagnostic pathology reports (with HPV status for oropharyngeal SCC) 

Johns Hopkins Protocol #: 
J1923  
 
Page 20 of 70 
 
o Pathology report(s) from initial diagnosis 
o Pathology report(s) from the recurrence 
 Baseline cross-sectional imaging (as clinically indicated, report sufficient for enrollment) 
 Laboratory reports including: 
o Complete blood count (CBC) with differential (including absolute lymphocyte count) and 
direct platelet count. 
o Chemistry: Albumin, SGOT (AST), SGPT (ALT), Bilirubin, Calcium, Creatinine, Glucose, 
Total protein, Urea nitrogen, Electrolytes (including sodium, potassium, chloride and 
bicarbonate). 
o Baseline thyroid function assay: Thyroid Stimulating Hormone (TSH). Abnormal 
endocrine results should be followed up per standard of care, and may require an 
endocrine consult and additional testing. 
 Medical records documenting treatment history of the initial therapy for SCCHN  before 
recurrence 
 Other documents, if requested. 
 
Study treatment cannot begin until the patient is registered and assigned to a treatment cohort. 
 
Subjects who sign a consent form but do not initiate protocol treatment for any reason (e.g., subjects 
who are screen failures), and patients who do not undergo surgical resection will be replaced and will 
not count towards our accrual goal of 26 patients (Patient allocation ideally should be 1:1 between 
both cohorts but may vary).  All patients who receive a dose of nivolumab will be evaluable for safety 
and feasibility.  
 
 Pre-treatment criteria 
 
Enrolled patients will need to meet the following criteria before receiving nivolumab. 
 
leukocytes 
≥ 1,500/mcL 
absolute neutrophil 
count 
≥ 1,000/mcL 
platelets 
≥ 100,000/mcL 
total bilirubin  
≤ 1.5 X institutional upper limit of normal 
(except subjects with Gilbert syndrome, who 
can have total bilirubin < 3.0 mg/dL) 
AST(SGOT)/ALT(SGPT) 
≤ 3 X institutional upper limit of normal 
Creatinine 
OR 
creatinine clearance 
within normal institutional limits 
OR 
≥ 40 mL/min (using modified Cockcroft-Gault 
formula) for patients with creatinine levels 
above institutional normal. 

Johns Hopkins Protocol #: 
J1923  
 
Page 21 of 70 
 
 
 Diagnostic and surgical evaluations 
 
All patients enrolled on this protocol must be surgical candidates with either locally recurrent SCCHN or 
oligometastatic SCCHN. Patients will have undergone radiographic evaluation indicating no evidence of 
disease outside the planned surgical field and main/target lesion/s should be determined to be 
amenable for resection by the treating surgeon.  
Distant metastatic disease is permissible if a clinical indication for surgery exists (e.g. in order to provide 
symptom control) and such distant disease can be addressed at an interval with systemic therapy (e.g. 
chemotherapy, targeted therapies, etc), or local therapies (e.g. radiation, metastatectomy) as clinically 
indicated. 
Any further preoperative testing that is recommended by the surgeon or anesthesiologist will be 
performed as part of standard of care. Surgery for patients enrolled on this protocol will be according to 
generally accepted standards of care. Patients should have baseline imaging as clinically appropriate of 
the affected area (neck/chest/abdomen and/or pelvis) – e.g. a CT or MRI with IV contrast and 
appropriate imaging should be repeated after completing neoadjuvant therapy, within the 7 days prior 
to planned surgery to assess response. 
 
 
Study drug administration  
 
Patients will receive 1 dose of nivolumab on approximately Day -28 prior to planned surgery on or after 
Day 0 and up to/including Day +14. A 14 day window is allowable (as needed for scheduling purposes, 
or if clinically appropriate for patients with clinical benefit/improvement, if deemed safe by the 
treating physicians (surgeon & medical oncologist). Furthermore if clinically indicated patients may 
undergo surgery earlier (see Section 4.1.2 regarding early surgery, salvage treatment). 
 
Nivolumab is to be administered as a 30 minute IV infusion.  
 
Nivolumab may be diluted in 0.9% Sodium Chloride Solution or 5% Dextrose solution. 
All subjects will receive nivolumab at a flat dose of 480 mg IV. 
 
Please refer to the current nivolumab investigators brochure for storage conditions. Recommended 
safety measures for preparation and handling of nivolumab include laboratory coats and gloves. 
 
For additional details on prepared drug storage and use time of nivolumab under room 
temperature/light and refrigeration, please refer to the BMS-936558 (nivolumab) current Investigator 
Brochure section for “Recommended Storage and Use Conditions”. There will be no dose escalations or 
reductions of study drugs allowed. There are no premedications recommended for nivolumab on the 
first dose. 
 
 
Management of Nivolumab -related infusion reactions 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 22 of 70 
 
Since nivolumab contains only human immunoglobulin protein sequences, it is unlikely to be 
immunogenic and induce infusion or hypersensitivity reactions. However, if such a reaction were to 
occur, it might manifest with fever, chills, rigors, headache, rash, pruritis, arthralgias, hypo- or 
hypertension, bronchospasm, or other symptoms. 
 
All Grade 3 or 4 infusion reactions should be reported as an SAE if criteria are met. Infusion reactions 
should be graded according to NCI CTCAE (Insert version e.g.: 4.0) guidelines. 
 
Treatment recommendations are provided below and may be modified based on local treatment 
standards and guidelines as appropriate: 
 
Grade 1 symptoms: (Mild reaction; infusion interruption not indicated; intervention not indicated) 
 
Remain at bedside and monitor subject until recovery from symptoms. The following prophylactic 
premedications are recommended for future infusions: diphenhydramine 50 mg (or equivalent) and/or 
paracetamol 325 to 1000 mg (acetaminophen) at least 30 minutes before additional nivolumab 
administrations. 
 
Grade 2 symptoms: (Moderate reaction requires therapy or infusion interruption but responds 
promptly to symptomatic treatment [eg, antihistamines, non-steroidal anti-inflammatory drugs, 
narcotics, corticosteroids, bronchodilators, IV fluids]; prophylactic medications indicated for 24 
hours). 
 
Stop the nivolumab infusion, begin an IV infusion of normal saline, and treat the subject with 
diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen);  
remain at bedside and monitor subject until resolution of symptoms. Corticosteroid or bronchodilator 
therapy may also be administered as appropriate. If the infusion is interrupted, then restart the  
infusion at 50% of the original infusion rate when symptoms resolve; if no further complications ensue 
after 30 minutes, the rate may be increased to 100% of the original infusion rate. Monitor subject 
closely. If symptoms recur then no further nivolumab will be administered at that visit. Administer 
diphenhydramine 50 mg IV, and remain at bedside and monitor the subject until resolution of 
symptoms. The amount of study drug infused must be recorded on the electronic case report form 
(eCRF). The following prophylactic premedications are recommended for future infusions:  
diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) should 
be administered at least 30 minutes before additional nivolumab administration. If necessary, 
corticosteroids (recommended dose: up to 25 mg of IV hydrocortisone or equivalent) may be used. 
 
Grade 3 or Grade 4 symptoms: (Severe reaction, Grade 3: prolonged [ie, not rapidly responsive to  
symptomatic medication and/or brief interruption of infusion]; recurrence of symptoms following 
initial improvement; hospitalization indicated for other clinical sequelae [eg, renal impairment, 
pulmonary infiltrates]).  
 

Johns Hopkins Protocol #: 
J1923  
 
Page 23 of 70 
 
Immediately discontinue infusion of nivolumab. Begin an IV infusion of normal saline, and treat the 
subject as follows. Recommend bronchodilators, epinephrine 0.2 to 1 mg of a 1:1,000 solution for 
subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 solution injected slowly for IV 
administration, and/or diphenhydramine 50 mg IV with methylprednisolone 100 mg IV (or equivalent), 
as needed. Subject should be monitored until the investigator is comfortable that the symptoms will 
not recur. Nivolumab will be permanently discontinued. Investigators should follow their institutional 
guidelines for the treatment of anaphylaxis. Remain at bedside and monitor subject until recovery 
from symptoms. In the case of late-occurring hypersensitivity symptoms (eg, appearance of a localized 
or generalized pruritis within 1 week after treatment), symptomatic treatment may be given  (eg, oral 
antihistamine, or corticosteroids). 
 
 
Surgical resection 
 
 Surgery for SCCHN patients with newly diagnosed and untreated locoregional disease: Cohort 1  
Extent of primary surgery and reconstruction will be decided by treating surgeons following the best 
clinical practice. 
 
 Surgery for SCCHN patients with locoregionally recurrent or oligometastatic disease: Cohort 2  
Salvage local surgery is a standard practice for patients with resectable locoregional recurrence.  
Metastatic disease is permissible and can be addressed with systemic or local therapies (radiation, 
surgery etc), at an interval as clinically indicated in addition to the local treatment. Surgical technique 
and extent will be decided by treating surgeons following the best clinical practice.  
 
 
Adjuvant treatment post surgery 
Postoperative radiotherapy with or without concurrent chemotherapy for subjects in both cohorts 
(cohort 1 and 2) will be determined based upon pathologic assessment and administered at the 
discretion of the treating multidisciplinary team based on established standard of care. Common 
scenarios indicating radiotherapy with concurrent chemotherapy may include high-risk pathologic 
findings such as positive margin or extranodal extension. Decision for or against postoperative 
radiotherapy with or without concurrent chemotherapy will be recorded.  
 
 
Evaluation of peri-operative safety 
 
Subject safety will be assessed at the regular trial safety meeting and adhoc as part of clinical care 
(including at the weekly tumor board with the surgeons) from the start of therapy until 100 days after 
the last dose of study treatment, or 30 days following surgery, whichever is longer, for information 
regarding operative complications including treatment-related delay in planned surgery and in 
particular potential immune related toxicities (Note: Only those subjects who initiate protocol 
treatment will be followed). Toxicities will be reviewed at regular meetings of study investigators and 
research staff and minutes of these meetings will be documented by the clinical research staff. In the 
event that a subject does not continue his or her peri-operative care at the institution, every attempt 
will be made to collect this information either by direct contact or through communication with the 

Johns Hopkins Protocol #: 
J1923  
 
Page 24 of 70 
 
subjects outside physician(s). 
 
 
Discontinuation, withdrawal and replacement of subjects 
 
All patients who receive at least one dose of study treatment (including those who do not undergo 
surgical resection of their tumor) will be included in the overall evaluation of safety (intention-to-treat 
analysis). All reasons for discontinuation of therapy should be documented clearly in the medical 
record. If a subject discontinues or withdraws from the study, every attempt will be made to obtain an 
off-study blood collection if the subject is able and willing to do so.  
 
Subjects who do not undergo surgical resection of their tumor, while evaluable for safety and 
feasibility, will not be evaluable for the key secondary endpoint of pathologic response. Subjects who 
sign a consent form but do not initiate protocol treatment for any reason (e.g., subjects who are screen 
failures), and patients who do not undergo surgical resection (for reasons unrelated to the study drug 
or toxicity) will be replaced and will not count towards our accrual goal. 
 
 
Discontinuation of treatment 
 
The reasons for discontinuation of protocol treatment include: 
 
 Evidence of significant disease progression during the preoperative phase at the discretion of the 
treating investigator.  
 
 Non-compliance with the study protocol; including, but not limited to not attending the majority 
of scheduled visits. The principal investigator will determine when non-compliance should lead 
to removal from study.  Note: The patients will still be included in the overall evaluation of safety 
(intent-to-treat analysis). 
 
 Unacceptable toxicity. Note: The patients will still be included in the overall evaluation of safety 
(intent-to-treat analysis).  
 
 Intercurrent illness or condition that would, in the judgment of the treating investigator, affect 
assessment of clinical status to a significant degree or require discontinuation of study 
treatment. 
 
 At subject’s own request. Note: The reason for discontinuation from the study must be 
documented. The patients will be included in the overall evaluation of safety (intent-to-treat 
analysis) if any protocol therapy was administered prior to withdrawal. 
 
 Study is closed for any reason (e.g. new information shows that the patient’s welfare would be 
at risk if he or she continued study treatment). 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 25 of 70 
 
   Study calendar 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 26 of 70 
 
 
 
 
Procedure 
Screening 
(Days -42 
to -29)a 
Day  
-28 
Pre-
surgical 
evaluation 
(Days -7 
to -1)** 
Day 0 
Surgery 
(up to 
day 
+14) 
Post-
surgical 
evaluation 
(Days 21 to 
42) 
Follow-up 
visits 
 (Every 3-4 
months for 1 yr; 
then every 6 
months for 2nd 
yr.)$$ 
At the 
time of 
recurrence 
Survival 
Follow-up 
(every 12 
months) 
Clinical Assessments 
Physical Exam 
X 
X 
X 
 
X 
X 
X 
 
Vital Signs 
X 
X 
X 
 
X 
X 
X 
 
Performance status (ECOG) 
X 
X 
X 
 
X 
X 
X 
 
Concomitant medicines 
X 
X 
X 
 
X 
X 
X 
 
Toxicity assessments 
X 
X 
X 
 
X 
X 
X 
 
Electrocardiogram (EKG) 
X 
 
 
 
 
 
 
 
Laboratory Tests 
CBC with diff 
X 
X**** 
X 
 
X 
X 
X 
 
Chemistry including LFT 
X 
X**** 
X 
 
X 
X 
X 
 
# IF abnormal LFTs draw:  
Hepatitis B/C serology 
(X)# 
 
 
 
 
 
 
 
TSH 
X 
 
 
 
X 
X 
 
 
Free T4 and T3 
X 
 
 
 
 
 
X 
 
PT/INR and PTT 
X 
 
X 
 
 
 
X 
 
Pregnancy Tests (WOCBP only) 
X 
 
X 
 
X 
 
X 
 
Treatment 
Nivolumab 
 
X 
 
 
 
 
 
 
CT neck/chest with IV contrast* 
X 
 
X 
 
 
(X) 
(X) 
 
MRI neck with IV contrast, 
opYonal† 
(X) 
 
(X) 
 
 
(X) 
(X) 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 27 of 70 
 
 
 
a. screening labs are permited to be used for treatment if completed within three (+3) days of day -28 
b. Research blood permited to be collected anytime after consent and prior to Nivolumab infusion (Days -42 to day -28) 
c. Patients are to be provided with a stool collection kit during screening (days -42 to -29) and instructed to collect a stool 
sample within 48 hours of their scheduled infusion day (day -28).   
d. Oral rinse is considered an optional collection during the first and second year follow up visits. 
*CT abdomen/pelvis can be added if there’s a clinical indication. MRI may replace or supplement CT scans if clinically appropriate. 
Ideally same imaging modality should be used for sequential imaging assessments. 
** can be done on day of sugery also if necessary. 
† MRI can be used at the treaYng physician’s discreYon; ideally same modality should be used throughout. 
(X) as clinically indicated 
*** Blood for correlates may be collected anytime after consent and prior to Nivolumab infusion. 
 
Procedure 
Screening 
(Days -42 
to -29) 
Day  
-28 
Pre-
surgical 
evaluation 
(Days -7 
to -1) 
Day 0 
(and up 
to day 
+14) 
Surgery 
Post-
surgical 
evaluation 
(Days 21 to 
42) 
Follow-up 
visits (Every 3-
4 months for 1 
yr; then every 6 
months for 2nd 
yr.)$$ 
At the 
time of 
recurrence 
Survival 
Follow-up 
(every 12 
months) 
Correlative Blood/Tissue/Stool Studies 
PBMCs, Serum, plasma 
(Blood collection 100 cc’s) 
 
Xb 
 
X 
X 
X 
X 
 
Tumor biopsy/sample 
X 
 
 
X 
(resection 
specimen) 
 
 
X 
 
 
 
 
 
 
 
 
 
 
Stool Sample 
 
XC 
      X 
X 
X 
X 
 
Oral Rinsed 
 
X 
 
 
X 
Xd 
X 
 
Medical & Dietary 
Questionnaire 
 
X 
 
 
X 
X 
X 
 
Survival 
 
 
 
 
 
 
 
X 

Johns Hopkins Protocol #: 
J1923  
 
Page 28 of 70 
 
***** Days -42 until/including Day -28 
 
$$ F/u visits are allowable +/- 28 days or as clinically indicated 
 
 See Appendix D for Sociodemographic Characteristics Questionnaire 

Johns Hopkins Protocol #: 
J1923  
 
Page 29 of 70 
 
 
5. DOSE DELAY AND TOXICITY MONITORING 
 
Dosing delays will not be permitted for this study. Prior to surgery, any treatment related 
toxicity should have resolved to ≤ Grade 2. Decision for surgery should be made by the treating 
medical oncologist and the surgeon.  
 
General management algoirthms for potential nivolumab-related toxicities are contained in 
Appendix of this protocol and in the Investigators Brochure. 
 
 
Dose-Limiting Toxicity 
 
Dose-Limiting toxicity (DLT) is defined as any of the items listed below that occur from the first 
dose of nivolumab through day 100 following the last dose of nivolumab (or day 30 post 
surgery, whichever is longer). Any patient who experiences a DLT will proceed to surgery after 
standard preoperative evaluation by a surgeon and anesthesiologist.  
 
 Any ≥ Grade 2 drug-related pneumonitis or interstitial lung disease that does not 
resolve to Grade 0 or 1 within 2 weeks with systemic steroids. The management 
algorithm for pneumonitis or pulmonary toxicity can be found in the appendix of 
current Investigator Brochure for nivolumab 
 Any ≥ Grade 2 drug-related uveitis or eye pain that does not respond to topical 
therapy and does not improve to Grade 1 severity within the retreatment period OR 
requires systemic treatment. If uveitis occurs during nivolumab treatment, workup 
and treatment should follow the nivolumab uveitis toxicity treatment algorithm 
located in the appendix of the nivolumab Investigators Brochure. 
 Any Grade 3 non-skin drug-related adverse event lasting ≥ 7 days with the exception 
of asymptomatic laboratory abnormalities. 
 Grade 3 drug-related bronchospasm, allergic reaction, or infusion-related reaction 
will be recorded and treated; however, it will not count as a dose-limiting toxicity for 
study purposes. 
 Any Grade 3 drug-related diarrhea that does not respond to dose delay and the use 
of systemic steroids within 2 weeks. If diarrhea occurs during nivolumab treatment, 
workup and treatment should follow the nivolumab diarrhea toxicity treatment 
algorithm located in the appendix of the nivolumab Investigators Brochure. 
 Any Grade 4 drug-related adverse event, including laboratory abnormalities apart 
from isolated Grade 4 electrolyte imbalances/abnormalities that are not associated 
with clinical sequelaeand are  corrected with appropriate management within 72 
hours of their onset. 
 Any of the following drug-related hepatic function laboratory abnormalities or 
potential Drug Induced Liver Injury (DILI): 
 
o AST or ALT > 5-10x ULN for > 2 weeks 

Johns Hopkins Protocol #: 
J1923  
 
Page 30 of 70 
 
o AST or ALT >10x ULN 
o Total bilirubin > 5 x ULN 
o Concurrent AST or ALT >3 x ULN and total bilirubin >2 x ULN 
 
 If suspected DILI occurs, workup and treatment should follow the nivolumab DILI 
treatment algorithm located in the appendix of the nivolumab Investigators Brochure. 
 Any other toxicity which is assessed by the principal investigator as having directly led to 
a delay in surgical resection more than 28 days past the planned Day 0 (or 14 days past 
D +14). 
 Failure to complete all protocol specified treatment doses due to toxicity (at the 
discretion of the PI). 
 
Note - Adverse events of special interest are nivolumab-related events with potential immune-
mediated causalities. For example, this may include cutaneous toxicities, colitis, liver function 
abnormalities (AST, ALT, total bilirubin, alkaline phosphatase), endocrine abnormalities 
(hyperthyroidism, hypothyroidism, hypophysitis and secondary adrenal insufficiency), 
interstitial pneumonitis and nephritis. These events will be noted. However, it may not 
constitute DLT’s unless they fulfill the previously outlined DLT criteria described above. 
 
6. ADVERSE EVENTS  
 
This study will use the descriptions and grading scales found in the revised National Cancer 
Institute Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0 for adverse 
event reporting that can be found at  https://ctep.cancer.gov/. 
 
Information about all adverse events, whether volunteered by the subject, discovered by 
investigator questioning, or detected through physical examination, laboratory test or other 
means, will be collected, recorded, and followed as appropriate.  
 
All adverse events experienced by subjects will be collected from the time of first dose of study 
medication, throughout the study and until 100 days post last dose of study drug. Subjects 
continuing to experience toxicity after discontinuation of the study drug may be contacted for 
additional assessments until the toxicity has resolved or is deemed irreversible.  
 
Any adverse event experienced during additional preoperative treatment or after the surgical 
procedure that the investigator feels is related to study treatment will be captured. 
 
 
Serious Adverse Events 
 
A Serious Adverse Event (SAE) is any untoward medical occurrence that at any dose:  
 results in death 
 is life-threatening (defined as an event in which the participant was at risk of death 
at the time of the event; it does not refer to an event which hypothetically might 
have caused death if it were more severe) 

Johns Hopkins Protocol #: 
J1923  
 
Page 31 of 70 
 
 requires inpatient hospitalization or causes prolongation of existing hospitalization 
(see NOTE below) 
 results in persistent or significant disability/incapacity 
 is a congenital anomaly/birth defect  
 is an important medical event (defined as a medical event(s) that may not be 
immediately life-threatening or result in death or hospitalization but, based upon 
appropriate medical and scientific judgment, may jeopardize the subject or may 
require intervention [eg, medical, surgical] to prevent one of the other serious 
outcomes listed in the definition above.) Examples of such events include, but are 
not limited to, intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization.)  
 Suspected transmission of an infectious agent (eg, pathogenic or nonpathogenic) 
via the study drug is an SAE.  
 
Although pregnancy, overdose, potential drug-induced liver injury (DILI), and cancer are not 
always serious by regulatory definition, these events must be handled as SAEs. 
 
Any component of a study endpoint that is considered related to study therapy should be 
reported as an SAE (eg, death is an endpoint, if death occurred due to anaphylaxis, anaphylaxis 
must be reported). 
 
NOTE: (PI determines if this information regarding hospitalizations are considered SAEs and 
should be included in the protocol. This is supplemental information that is included in 
BMS-sponsored trials) 
 
The following hospitalizations are not considered SAEs in BMS clinical studies:  
 
 a visit to the emergency room or other hospital department < 24 hours, that does 
not result in admission (unless considered an important medical or life-
threatening event) 
 elective surgery, planned prior to signing consent 
 admissions as per protocol for a planned medical/surgical procedure 
 routine health assessment requiring admission for baseline/trending of health 
status (eg, routine colonoscopy) 
 Medical/surgical admission other than to remedy ill health and planned prior to 
entry into the study. Appropriate documentation is required in these cases. 
 Admission encountered for another life circumstance that carries no bearing on 
health status and requires no medical/surgical intervention (eg, lack of housing, 
economic inadequacy, caregiver respite, family circumstances, administrative 
reason). 
 Admission for administration of anticancer therapy in the absence of any other 
SAEs (applies to oncology protocols) 

Johns Hopkins Protocol #: 
J1923  
 
Page 32 of 70 
 
 
 
Adverse Events 
 
An Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of a 
preexisting medical condition in a clinical investigation participant administered  study drug 
and that does not necessarily have a causal relationship with this treatment. An AE can 
therefore be any unfavorable and unintended sign (such as an abnormal  laboratory finding), 
symptom, or disease temporally associated with the use of investigational product, whether or 
not considered related to the investigational product. 
 
The causal relationship to study drug is determined by a physician and should be  used to assess 
all adverse events (AE). The casual relationship can be one of the  following: 
 
Related: There is a reasonable causal relationship between study drug administration and the 
AE. 
 
Not related: There is not a reasonable causal relationship between study drug administration 
and the AE.  
 
The term "reasonable causal relationship" means there is evidence to suggest a causal 
relationship.  
 
Adverse events can be spontaneously reported or elicited during open-endedquestioning, 
examination, or evaluation of a subject. (In order to prevent reporting bias,  
subjects should not be questioned regarding the specific occurrence of one or more AEs.) 
 
 Unexpected adverse event 
 
An adverse event, which varies in nature, intensity or frequency from information on the  
investigational drug/agent provided in the Investigator’s Brochure, package insert or safety 
reports. Any adverse event that is not included in the informed consent is considered 
“unexpected”. 
 
 Expected (known) adverse event 
 
An adverse event, which has been reported in the Investigator’s Brochure. An adverse event is 
considered “expected”, only if it is included in the informed consent document as a risk. 
 
 
Nonserious Adverse Events 
 
 Non-serious Adverse Events (AE) are to be provided to BMS in aggregate via interim or 
final study reports as specified in the agreement or, if a regulatory requirement [eg, IND 
US trial] as part of an annual reporting requirement.  
 Non-serious AE information should also be collected from the start of a placebo lead-in 

Johns Hopkins Protocol #: 
J1923  
 
Page 33 of 70 
 
period or other observational period intended to establish a baseline status for the 
subjects.  
 A non-serious adverse event is an AE not classified as serious. 
 
Non-serious Adverse Event Collection and Reporting 
The collection of non-serious AE information should begin at initiation of study drug. All 
non-serious adverse events (not only those deemed to be treatment-related) should be 
collected continuously during the treatment period and for a minimum of (provide # of days 
depending on the asset and study type)  days following the last dose  of study treatment.  
 
Non-serious AEs should be followed to resolution or stabilization, or reported as SAEs if  they 
become serious. Follow-up is also required for non-serious AEs that cause interruption or 
discontinuation of study drug and for those present at the end of study treatment as 
appropriate.  
 
 
Laboratory Test Abnormalities 
 
All laboratory test results captured as part of the study should be recorded following 
institutional procedures. Test results that constitute SAEs should be documented and reported 
to BMS as such. 
 
The following laboratory abnormalities should be documented and reported appropriately: 
 
 any laboratory test result that is clinically significant or meets the definition of an SAE 
 any laboratory abnormality that required the participant to have study drug 
discontinued or interrupted 
 any laboratory abnormality that required the subject to receive specific  corrective 
therapy.  
 
It is expected that wherever possible, the clinical rather than laboratory term would be  used 
by the reporting investigator (eg, anemia versus low hemoglobin value). 
 
6.5  
Potential Drug Induced Liver Injury (DILI)  
 
 
Specific criteria for identifying potential DILI have not been identified for this 
 
protocol. Standard medical practice in identifying and monitoring hepatic issues should 
 
be followed. 
 
Wherever possible, timely confirmation of initial liver-related laboratory abnormalities 
 
should occur prior to the reporting of a potential DILI event. All occurrences of potential 
 
DILIs, meeting the defined criteria, must be reported as SAEs. 
 
Potential drug induced liver injury is defined as:  
 
1. ALT or AST elevation > 3 times upper limit of normal (ULN) 
AND 

Johns Hopkins Protocol #: 
J1923  
 
Page 34 of 70 
 
2. Total bilirubin > 2 times ULN, without initial findings of cholestasis (elevated serum 
alkaline phosphatase) 
AND 
3. No other immediately apparent possible causes of AT elevation and hyperbilirubinemia, 
including, but not limited to, viral hepatitis, pre-existing chronic or acute liver disease, or 
the administration of other drug(s) known to be hepatotoxic. 
 
Wherever possible, timely confirmation of initial liver-related laboratory  abnormalities should 
occur prior to the reporting of a potential DILI event. All  occurrences of potential DILIs, meeting 
the defined criteria, must be reported as  SAEs. 
 
 
6.6  Pregnancy 
 
If, following initiation of the investigational product, it is subsequently discovered that a  study 
participant is pregnant or may have been pregnant at the time of investigational  product 
exposure, including during at least 5 half-lives after product administration, the  investigational 
product will be permanently discontinued in an appropriate manner (eg,  dose tapering if 
necessary for participant).  
 
 
The investigator must immediately notify Worldwide.Safety@bms.com of this event via  either 
the CIOMS, MedWatch or appropriate Pregnancy Surveillance Form in accordance with SAE 
reporting procedures.  
 
 
Protocol-required procedures for study discontinuation and follow-up must be performed on 
the participant. 
 
 
Follow-up information regarding the course of the pregnancy, including perinatal and neonatal 
outcome and, where applicable, offspring information must be reported on the CIOMS, 
MedWatch, BMS Pregnancy Surveillance Form, or approved site SAE form.  A BMS Pregnancy 
Surveillance Form may be provided upon request. 
 
Any pregnancy that occurs in a female partner of a male study participant should be reported 
to BMS. Information on this pregnancy will be collected on the Pregnancy Surveillance Form. In 
order for Sponsor or designee to collect any pregnancy surveillance information from the 
female partner, the female partner must sign an informed consent form for disclosure of this 
information.  
 
6.7  
Overdose 
 
An overdose is defined as the accidental or intentional administration of any dose of a product 
that is considered both excessive and medically important. All occurrences of overdose must be 
reported as SAEs (see Section 6.3 for reporting details). 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 35 of 70 
 
6.8   
Other Safety Considerations 
 
Any significant worsening noted during interim or final physical examinations, 
electrocardiograms, X-rays, and any other potential safety assessments, whether or not  these 
procedures are required by the protocol, should also be recorded as a non-serious or serious 
AE, as appropriate, and reported accordingly.  
 
6.9  Adverse Event Attributions 
 
The attributions are assessed by an investigator and assigned as followings: 
 
 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. 
 
6.10   Serious Adverse Event Reporting 
 
Following the subject’s written consent to participate in the study, all SAEs, whether related or 
not related to study drug, must be collected, including those thought to be associated with 
protocol-specified procedures. 
 
 All Serious Adverse Events (SAEs) that occur following the subject’s written consent to 
participate in the study through 100 days of discontinuation for those subjects that 
receive study therapy (within 30 days of last visit for enrollment failure)    The 
Investigator should report any SAE occurring after these time periods that is believed to 
be related to study drug or protocol-specified procedure. 
 An SAE report should be completed for any event where doubt exists regarding its 
status of seriousness.  If the investigator believes that an SAE is not related to study 
drug, but is potentially related to the conditions of the study (such as withdrawal of 
previous therapy, or a complication of a study procedure), the relationship should be 
specified in the narrative section of the SAE report form. 
 All SAEs, whether related or unrelated to nivolumab and all pregnancies must be 
reported to BMS (by the investigator or designee) within 24 hours. 
 The principal investigator or their designee will notify the appropriate regulatory 
agencies of any serious adverse event due to any cause during the course of this 
investigation.  These include the Johns Hopkins Cancer Center Data and Safety 
Monitoring Committee, and the Johns Hopkins Medical Institutional Review Board 
(JHM-IRB) of the Johns Hopkins Medical Institutions.  The required reporting time period 
is 3 days for fatal events, and 10 days for all other events. 

Johns Hopkins Protocol #: 
J1923  
 
Page 36 of 70 
 
 For studies conducted under and Investigator IND, any event that is both serious and 
unexpected must be reported to the Food and Drug Administration (FDA) as soon as 
possible and no later than 7 days (for a death or life-threatening event) or 15 days (for 
all other SAEs) after the investigator’s or institutuion’s initial receipt of the information.  
BMS will be provided with a simultaneous copy of all adverse events filed with the FDA.  
SAEs should be reported on MedWatch Form 3500A or similar form  It MUST include the 
institutional AND BMS study ID. 
 
MedWatch SAE forms should be sent to the FDA with reference to the IND 
under which this study is being conducted.  
 
All SAEs should simultaneously be faxed or e-mailed to BMS at: 
Global Pharmacovigilance & Epidemiology 
Bristol-Myers Squibb Company 
Fax:  609-818-3804 
SAE Email Address:  worldwide.safety@bms.com 
 
The study period during which adverse events will be reported is form the initiation of study 
procedures to the end of the study treatment follow-up, defined as 100 days following the last 
administration of nivolumab treatment. 
 
If only limited information is initially available, follow-up reports are required.  (Note:  Follow-
up SAE reports should include the same investigator term(s) initially reported.  If an ongoing 
SAE changes in its intensity or relationship to study drug or if new information becomes 
available, a follow-up SAE report should be sent to BMS using the same procedure used for 
transmitting the initial SAE report. 
 
In accordance with local regulations, BMS will notify investigators of all SAEs that are suspected 
(related to the investigational product) and unexpected (ie, not previously described in the 
Investigator Brochre).  In the European Union (EU), an event meeting these criteria is termed a 
Suspected, Unexpected Serious Adverse Reaction (SUSAR). 
 
Investigator notification of these events will be in the form of an expedited safety report (ESR) 
provided through the FastTrack portal system. 
 
SAEs must be recorded on the SAE Report Form.  If only limited information is initially available, 
follow-up reports are required.  (Note:  Follow-up SAE reports should include the same 
investigator term(s) initially reported.   
 
If an ongoing SAE changes in its intensity or relationship to study drug or if new information 
becomes available, a follow-up SAE report should be sent within 24 hours.   
 

Johns Hopkins Protocol #: 
J1923  
 
Page 37 of 70 
 
All SAEs should be followed to resolution or stabilization. 
 
The Sponsor will reconcile the clinical database SAE cases (case level only) transmitted to BMS 
Global Pharamacovigilance (WoldwideWorldwide.Safety@bms). Frequency of reconciliation 
should be every 3 months and prior to the database lock or final data summary. BMS GPV&E 
will email, upon request from the Investigator, the GPV&E reconciliation report. Requests for 
reconciliation should be sent to aepbusinessprocess@bms.com. The data elements listed on 
the GPV&E reconciliation report will be used for case identification purposes. If the Investigator 
determines a case was not transmitted to BMS GPV&E, the case should be sent immediately to 
BMS. 
 
6.11  Non-serious Adverse Event Collection and Reporting 
The collection of non-serious AE information should begin at initiation of the study drug. Non-
serious AE information should also be collected from the start of the observational 
periodintended to establish a baseline status for the subjects.  
All non-serious adverse events (not only those deemed to be treatment-related) should be 
collected continuously during the treatment period and for a minimum of 90 days following the 
last dose of study treatment. 
Non-serious AEs should be followed to resolution or stabilization, or reported as SAEs if they 
become serious.  Follow-up is also required for non-serious AEs that cuase interruption or 
discontinuation of study drug, or those that are present at the end of study treatment as 
appropriate.  All identified non-serious AEs must be repocrded and described on the non-
serious AE page of the CRF (paper or electronic).  
7.  DATA AND SAFETY MONITORING  
 
  Data Management 
 
 
Confidentiality  
 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
 
 Source Documents  
 
Source data include all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  
 
 Case Report Forms  
 
The study case report forms (CRFs) are the primary data collection instrument for the study. All 
data requested on the CRF will be recorded for each subject. If a procedure was not done or a 

Johns Hopkins Protocol #: 
J1923  
 
Page 38 of 70 
 
question was not asked, this will be recorded as “N/D”. If the item is not applicable to the 
individual case, this will be recorded as “N/A”. CRFs will be built electronically in Johns Hopkins 
RedCap (or CRMS).  All data will be entered electronically onto the electronic CRF through Johns 
Hopkins RedCap (or CRMS) by the Study Coordinator and/ or Data Manager from each site. 
 
The completed forms will be forwarded for central review and inclusion in the study dataset 
with relevant source documentation as outlined in the case report forms. The data submission 
schedule is as follows: 
 
At the time of registration: 
 Informed Consent Form (signed by the subject) 
 Eligibility Checklist 
 Source documents related to eligibility 
 
Within 2 weeks after registration: 
 Baseline study case report forms 
 Pertinent source documents 
 
Within 2 weeks after final dose of study medication: 
 On study case report forms 
 Pertinent source documents 
 
 Safety Monitoring 
 
7.2.1  Auditing and Monitoring  
 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, 
government regulatory bodies, University compliance and quality assurance groups. The 
investigator will ensure the capability for inspections of applicable study-related facilities (e.g. 
pharmacy, diagnostic laboratory, etc.).  
 
The PI shall internally monitor the progress of the trial, including review and confirmation of all 
safety/treatment-related outcomes, response assessments, safety reports and/or any related 
source documentation.  
 
The SKCCC Compliance Monitoring Program will provide external monitoring for JHU-affiliated 
sites in accordance with SKCCC DSMP (Version 6.0, 02/21/2019).  The SMC Subcommittee will 
determine the level of patient safety risk and level/frequency of monitoring. 
 
Ethical Considerations  
 
This study is to be conducted according to US and international standards of Good Clinical 
Practice (FDA Title 21 part 312 and International Conference on Harmonization guidelines), 
applicable government regulations and Institutional research policies and procedures. 

Johns Hopkins Protocol #: 
J1923  
 
Page 39 of 70 
 
 
This protocol and any amendments will be submitted to a properly constituted independent 
Ethics Committee (EC) or Institutional Review Board (IRB), in agreement with local legal 
prescriptions, for formal approval of the study conduct. The decision of the EC/IRB concerning 
the conduct of the study will be made to the investigator before commencement of this study. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in 
this study. The consent form will be submitted with the protocol for review and approval by the 
EC/IRB for the study. The formal consent of a subject, using the EC/IRB-approved consent form, 
must be obtained before that subject is submitted to any study procedure. This consent form 
must be signed by the subject or legally acceptable surrogate, and the investigator-designated 
research professional obtaining the consent. 
 
8.  PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the agents administered in this 
study can be found in Section 6 and Investigator’s Brochures of nivolumab. 
 
 
 Nivolumab 
 
 Fully human anti-PD-1 IgG4: monoclonal antibody 
Other names: BMS-936558, MDX-1106  
Classification: Monoclonal antibody; impedes PD-1/PD-L1 interaction  
 How Supplied: Nivolumab is provided as a sterile liquid in vials each containing 
100mg/10ml of the monoclonal antibody and 5 vials per carton. 
 Mechanism of Action: Nivolumab is a monoclonal antibody that binds to the cell surface 
protein PD-1, a key regulator of cytotoxic T lymphocyte activation.  Nivolumab inhibits 
PD-1/PD-L1 and PD-1/PD-L2 interaction, facilitating CTL reactivity and promoting an 
anticancer cytolytic response.  
 Route of Administration: Nivolumab is to be administered as an intravenous infusion, 
using a volumetric pump with a 0.2 micron in-line filter at the protocol-specified doses. 
It is not to be administered as an intravenous push or bolus injection. At the end of the 
infusion, the line should be flushed with a sufficient quantity of normal saline.  A 30 
minute infusion, can be diluted with 0.9% NS for delivery but the total drug 
concentration of the solution cannot be below 0.35mg/ml. 
 Storage and Stability: Nivolumab vials must be stored at a temperature of 2°C to 8°C and 
should be protected from light. If stored in a glass front refrigerator, vials should be 
stored in the carton. Recommended safety measures for preparation and handling of 
Nivolumab include laboratory coats and gloves. After Nivolumab has been prepared for 
administration, the total storage time (combination of refrigeration and room 
temperature) is not to exceed 24 hours.  Stability data for Nivolumab following dilution 
and transfer to the IV bag supports either: 24 hours at 2°C to 8°C in the refrigerator, or 8 
hours at room temperature/under room light and 18 hours at 2°C to 8°C in the 

Johns Hopkins Protocol #: 
J1923  
 
Page 40 of 70 
 
refrigerator. Care must be taken to assure sterility of the prepared solution as the 
product does not contain any anti-microbial preservative or bacteriostatic agent. No 
incompatibilities between Nivolumab and polyolefin bags have been observed.  
 Potential Drug Interactions: Studies examining interactions between Nivolumab and 
other agents are ongoing. 
 Nivolumab will be supplied directly from BMS Inc..  The IDS Pharmacy will be 
responsible for ordering the study drug directly from BMS Inc. 
 Pharmacy:  Prepare in Non-PVC bag.  Final concentration will be > 0.35mg/ml.  Mix to 
total volume of 60ml NSS. If dose volume > 60ml, use straight drug.  Prime tubing with 
NSS and attach to bag.  Infuse via 0.2 micron filter.  Send inline filter to clinic. 
Nurse:  Attach inline filter to patient side of pump 
Investigational supply of Nivolumab is obtained from Bristol Myers Squibb. Drug 
supplies, will be kept in a secure, limited access storage area under the storage 
conditions. Where necessary, a temperature log must be maintained to make certain 
that the drug supplies are stored at the correct temperature. 
 
The responsible person must maintain records of the product’s delivery to the study 
site, the inventory at the site and the use by each patient. The Principal Investigator 
(and participating site investigators)  are responsible for all destructions/disposals of 
partially used and unused supplies.  Supplies are not to be shipped back to BMS.  A 
copy of the drug destruction certificate must be maintained for provision to BMS at the 
end of the study. 
 
These records will include dates, quantities, batch/serial numbers, expiry (“use by”) 
dates, and the unique code numbers assigned to the investigational product(s) and 
study patients. The responsible person will maintain records that document adequately 
that the patients were provided the doses specified by the CSP and reconcile all 
investigational product(s) received from BMS. 
 
 
 
 
 
9. MEASUREMENT OF EFFECT 
 
 
Pathologic evaluation 
 
Assessment of immune related pathologic response (irPRC) is the first secondary endpoint of 
the study as defined by Stein et al.51  
Diagnostic pathology specimen will be collected and processed following the treating 
institution’s standard operating procedures and will be evaluated by a head and neck 
pathologist.  
 
Major pathologic response (mPR) will also be assessed and is defined as < 10% residual tumor 

Johns Hopkins Protocol #: 
J1923  
 
Page 41 of 70 
 
tissue on all reviewed specimens of each subject.  
 
 
Radiographic evaluation 
 
Radigraphic response is the third secondary endpoint of the study. On this study, planned 
radiologic evaluations will be performed at baseline and after 4 weeks of therapy prior to 
planned surgical resection.  
 
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009], Changes in the longest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria. 
 
Evidence of PD will be based on a comparison with baseline (or nadir) scans, in which there is 
either an increase of 20% or more in the sum of the longest diameters (SLD) of target lesions 
taking as reference the smallest sum of the longest diameters (nadir) recorded since starting 
nivolumab treatment, and/or unequivocal progression of non-target lesions, with or without 
the development of 1 or more new lesions.  Because all subjects are intended to get surgical 
resection, confirmatory scans are not required.  
 
 Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of their first 
treatment on protocol. 
 
Evaluable for objective response. All patients will be evaluable for objective response after 
completing the first treatment on protocol, as long as they get radiographic evaluation with 
either CT scans or MRI scans on the specified timeframe.  
 
 Disease Parameters 
 
To assess objective response or future progression, it is necessary to estimate the overall tumor 
burden at baseline and use this as a comparator for subsequent measurements.  Measurable 
disease is defined by the presence of at least one measurable lesion. 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately measured 
in at least one dimension (longest diameter to be recorded) as >20 mm by chest x-ray or as >10 
mm with CT scan, MRI, or calipers by clinical exam.  All tumor measurements must be recorded 
in millimeters (or decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area are not considered 
measurable unless there has been demonstrated progression in the lesion. 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 42 of 70 
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph 
node must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm).  At baseline and in follow-up, only the short axis 
will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitic involvement of the skin or lung, inflammatory breast disease, and 
abdominal masses/abdominal organomegaly (not followed by CT or MRI), are considered as 
non-measurable. 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, 
on occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum 
diameters will be used as reference to further characterize any objective tumor regression in 
the measurable dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, 
absence, or in rare cases unequivocal progression of each should be noted throughout follow-
up.  
 
 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment 
and never more than 4 weeks before the beginning of the treatment. 

Johns Hopkins Protocol #: 
J1923  
 
Page 43 of 70 
 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam. 
 
Clinical lesions  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed using calipers 
(e.g., skin nodules).  In the case of skin lesions, documentation by color photography, including 
a ruler to estimate the size of the lesion, is recommended.  
 
Conventional CT and MRI  This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice thickness 
greater than 5 mm, the minimum size for a measurable lesion should be twice the slice 
thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally.  As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease.  
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence.  It is 
beyond the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters 
for all scanners, body parts, and diseases.  Ideally, the same type of scanner should be used and 
the image acquisition protocol should be followed as closely as possible to prior scans.  Body 
scans should be performed with breath-hold scanning techniques, if possible. 
 
PET-CT  At present, the low dose or attenuation correction CT portion of a combined PET-CT is 
not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if the 
site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to 
a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for 
RECIST measurements and can be used interchangeably with conventional CT in accurately 
measuring cancer lesions over time.  Note, however, that the PET portion of the CT introduces 
additional data which may bias an investigator if it is not routinely or serially performed.   
 
Ultrasound  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to 
the next.  If new lesions are identified by ultrasound in the course of the study, confirmation by 
CT or MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used 
instead of CT in selected instances. 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 44 of 70 
 
 Response Criteria 
 
9.2.4.1 Evaluation of Target Lesions 
 
Immune related pathologic response criteria (irPRC) 
irPRC response will be assessed as described by Stein et al by Dr. Lisa Rooper/a board certified 
pathologist trained in irPRC assessment.51 
 
Radiologic Response: 
Complete Response (CR): Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm. 
 
Partial Response (PR):  At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum diameters. 
 
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study).  In addition to the relative increase of 20%, the sum must also demonstrate 
an absolute increase of at least 5 mm.  (Note:  the appearance of one or more new lesions is 
also considered progressions). 
 
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum diameters while on study. 
 
Special notes on the assessment of target lesions: 
Lymph nodes:  Lymph nodes identified as target lesions should always have the actual short 
axis measurement recorded and should be measured in the same anatomical plane as the 
baseline examination, even if the nodes regress to below 10mm on study.  This means that 
when lymph nodes are included as target lesions, the ‘sum’ of lesions may not be zero even if 
complete response criteria are met, since a normal lymph node is defined as having a short axis 
of < 10 mm. 
 
Target lesions that become ‘too small to measure’:  All lesions (nodal and non-nodal) recorded 
at baseline should have their actual measurements recorded at each subsequent evaluation, 
even when very small (eg, 2mm).  If the radiologist is able to provide an actual measure, that 
should be recorded, even if it is below 5mm.  When such a lesion becomes difficult to assign an 
exact measurement, it is recommended to:  If it is in the opinion of the radiologist that the 
lesion has likely disappeared, the measurement should be recorded as 0 mm.  If the lesion is 
believed to be present and is faintly seen but too small to measure, a default value of 5 mm 
should be assigned (note: in case of a lymph node believed to be present and faintly seen but 
too small to measure, a default value of 5 mm should be assigned in this circumstance as well).  
This default value is derived from the 5 mm CT slice thickness (but should not be changed with 
varying CT slice thickness). 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 45 of 70 
 
Lesions that split or coalesce on treatment:  When non-nodal lesions ‘fragment’, the longest 
diameters of the fragmented portions should be added together to calculate the target lesion 
sum.  Similarly, as lesions coalesce, a plane between them may be maintained that would aid in 
obtaining maximal diameter measurements of each individual lesion.  If the lesions have 
coalesced such that they are no longer separable, the vector of the longest diameter in this 
instance should be the maximal longest diameter for the ‘coalesced lesion’. 
 
9.2.4.2 Evaluation of Non-Target Lesions 
 
Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm short axis). 
 
Note: If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response. 
 
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits. 
 
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions.  Unequivocal progression should not normally trump 
target lesion status.  It must be representative of overall disease status change, not a single 
lesion increase.     
 
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or Principal Investigator).  When the patient also 
has measurable disease:  To achieve ‘unequivocal progression’ on the basis of the non-target 
disease, there must be an overall level of substantial worsening in non-target disease such that, 
even in presence of SD or PR in target disease, the overall tumor burden has increased 
sufficiently to merit discontinuation of therapy.  A modest ‘increase’ in size of one or more non-
target lesions is usually not sufficient to qualify for unequivocal progression status.  When the 
patients has only non-measurable disease:  To achieve ‘unequivocal progression’ on the basis of 
the non-target disease, there must be an overall level of substantial worsening such that the 
overall tumor burden has increased sufficiently to merit discontinuation of therapy.  A modest 
‘increase’ in the size of one or more non-target lesions is usually not sufficient to qualify for 
unequivocal progression status.  Because worsening in non-target disease cannot be easily 
quantified (by definition: if all lesions are non-measurable) a useful test that can be applied 
when assessing patients for unequivocal progression is to consider if the increase in overall 
disease burden based on the change in non-measurable disease is comparable in magnitude to 
the increase that would be required to declare PD for measurable disease: i.e., an increase in 
tumor burden representing an additional 73% increase in ‘volume’ (which is equivalent to a 
20% increase diameter in a measurable lesion).  Examples include an increase in a pleural 
effusion from ‘trace’ to ‘large’, an increase in lymphangitic disease from localized to 
widespread, or may be described in protocols as ‘sufficient to require a change in therapy’.  If 

Johns Hopkins Protocol #: 
J1923  
 
Page 46 of 70 
 
‘unequivocal progression’ is seen, the patient should be considered to have had overall PD at 
that point. 
 
 
 Progression-Free Survival 
 
PFS is defined as the duration of time from start of nivolumab treatment to time of progression 
or death, whichever occurs first. 
 
10. STATISTICAL CONSIDERATIONS 
 
 Study Design/Endpoints 
 
 Study Design 
 
Patients will receive 1 dose of nivolumab, 480mg IV on Day -28 prior to planned surgery on or 
after Day 0 and up to/including Day +14. A 14 day window is allowable (as needed for 
scheduling purposes, or if clinically appropriate for patients with clinical benefit/improvement, 
if deemed safe by the treating physicians (surgeon & medical oncologist). Furthermore if 
clinically indicated patients may undergo surgery earlier (see Section 4.1.2 regarding early 
surgery, salvage treatment). 
 
Patients will be observed for perioperative grade 3-4 adverse events through day 100 (or day 
30 post surgery – whichever is longer) following the last dose of study drug(s). Safety and 
feasibility will be monitored continually throughout the study through biweekly meetings with 
investigators. A set of markers of immune reactivity measured in the tumor resection 
specimens, draining lymph nodes, and peripheral blood will be evaluated. Feasibility in this 
study means the successful completion of preoperative treatment and proceeding to surgery 
without any extended treatment related delays. Extended treatment-related delay is defined as 
> 28 days from preplanned Day 0 in this context (or accordingly >14 days from day +14).  
 
 Endpoints 
 
Primary Endpoint 
 
Safety and feasibility of neoadjuvant nivolumab administration in patients with newly 
diagnosed head and neck cancer and those with locoregional recurrence or oligometastatic 
disease undergoing surgical resection, measured by 1) frequency of drug-related adverse 
events occurring up to 100 days after the last dose of nivolumab or 30 days after surgery 
(whichever is longer), and 2) successful completion of preoperative treatment and proceeding 
to surgery without any extended treatment-related delays greater than 28 days from the 
preplanned day 0 (or 14 days from day +14).  
 
Secondary Endpoints 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 47 of 70 
 
Immune related pathologic response (irPRC) 
As defined by Stein et al (CCR 2019)51 
 
Major pathologic response rate  
Defined as < 10% residual tumor in the resection specimen after neoadjuvant nivolumab 
 
Progression-free survival 
Progression-free survival will be measured from the time of initiation of nivolumab until  
radiologic or clinical progression or death.   
 
Radiographic response rate 
Response will be determined by RECIST version 1.1. 
 
Laboratory correlates of immune activity and response 
 
 Sample Size, Analysis, and Accrual Rate 
 
This study is investigating the safety and feasibility of neoadjuvant nivolumab administration in 
patients with locoregional newly diagnosed, recurrent or oligometastatic disease undergoing 
surgical resection.The study will enroll patients in two cohorts with an expected 12 patients in 
each cohort (although exact allocation may vary), who will undergo surgery in each cohort; the 
total sample size will be up to 26 patients. Subjects who sign a consent form but do not initiate 
protocol treatment for any reason (e.g., subjects who are screen failures), and patients who do 
not undergo surgical resection (for reasons unrelated to the study drug or toxicity) will be 
replaced and will not count towards our accrual goal. 
 
The goal for the primary analysis of safety is to estimate the rate of DLTs (as defined in section 
5.1) (AEs). We will provide the proportion of patients experiencing AEs, along with 95% 
confidence interval. Based on our study of neoadjuvant nivolumab in resectable lung cancer, 
we assume that at most 5% of patients will develop drug-related AEs of grade 3 or higher. The 
estimate and corresponding two-sided 95% confidence interval (CI) for each cohort is listed in 
the table below and may be updated if allocation between cohorts is not balanced: 
 
 
Observed number of patients 
with grade 3 or higher toxicity 
Observed rate 
95% CI (Clopper-Pearson) 
0 
0 
0% - 26.5% 
1 
8.3% 
0.2% - 38.5% 
2 
16.7% 
2.1% - 48.4% 
 
For feasibility, the estimate of percent patient proceeding to surgery without any extended 
treatment related delays and the corresponding 95% CI based on 11-12 patients is, but may be 
updated if allocation between cohorts varies further: 

Johns Hopkins Protocol #: 
J1923  
 
Page 48 of 70 
 
 
Observed number of patients 
proceeding to surgery without 
extended delay 
Observed rate 
95% CI (Clopper-Pearson) 
12 
100% 
73.5% - 100% 
11 
91.7% 
61.5% - 99.8% 
 
However, cohort size (e.g. in the case of imbalanced enrollment) may be split 13/11, or 14/10. 
after consultation with the study statistician. 
 
Surgical resection for head and neck cancers is standard of care.  With regards to the recurrent 
population, this study targets a niche population, and historically there has been no dedicated 
trial for these patients. Typically surgeons perform at least 2-4 operations in patients 
appropriate for this study per month at  a high volume academic institution, and thus expected 
accrual is 1-4 per month. For 26-patient study, it will take approximately 12-18 months with a 
high volume academic site such as Johns Hopkins University.  
 
 
Endpoints: 
Feasibility will be evaluated as the successful completion of preoperative treatment and 
proceeding to surgery without any extended treatment-related delays defined as >28 days from 
preplanned Day 0 in this context (or 14 days if surgery is performed Day +14). 
 
Safety will be measured by: 
 
Frequency of drug-related adverse events occurring from the (first) dose of 
nivolumab up to 100 days after the last dose of study treatment or 30 days after 
surgery (whichever is longer). 
 
Frequency of serious adverse events occurring from the (first) dose of nivolumab up 
to 100 days after the last dose of study treatment or 30 days after surgery 
(whichever is longer). 
 
Frequency of clinical laboratory test by worst toxicity grade using NCI CTCAE v5 (as 
assessed at the time intervals outlined in the study calendar 4.10). 
 
Safety and feasibility will be monitored continually throughout the study.  
Safety stopping guideline: For the neoadjuvant nivolumab cohorts we will temporarily halt the 
accrual if the risk of grade 3-4 toxicities appears to be higher than 25% (i.e., posterior 
probability that the risk > 25% is 0.7 or higher). We use a stopping rule based on a Beta prior 
distribution with parameters 1 and 3.  With this prior, there is 90% probability that this risk of 
high-grade toxicity is between 1.7% and 63.2%.  The safety stopping rule for the two single-
agent cohorts applies this prior distribution to the observed number of patients experiencing 
high-grade toxicity and to compute the resulting risk of such toxicities.  If, given the data from 
patients already treated, the probability is at least 70% that the risk is greater than 25%, we will 
consider stopping treatment. Starting from the 2nd patients, the safety stopping guidelines are 

Johns Hopkins Protocol #: 
J1923  
 
Page 49 of 70 
 
shown in Tabel 1. 
Table 1.  Stopping rule for safety. 
Stop if  there are this many grade 3 or 
higher AEs 
2 
3 
4 
5 
In this many patients 
2-4 
5-8 
9-11 
12 
 
Operating characteristics of the safety stopping rule are shown below and are based on 5,000 
simulatins: 
 
Risk of AE 
0.15 
0.20 
0.25 
0.30 
0.35 
0.40 
% of Time study stops 
16.7% 
30% 
42.2% 
55.4% 
69% 
78.7% 
Expected sample size 
10.8 
10 
9.1 
8.2 
7.1 
6.3 
 
 
Feasibility stopping guideline: We will temporarily halt the accrual if the risk of delayed surgery 
due to neoadjuvant nivolumab appears to be higher than 25%. We use a stopping rule based on 
a Beta prior distribution with parameters 0.1 and 0.9.  With this prior, there is 90% probability 
that this risk of high-grade toxicity is between 0 and 65%.  If, given the data from patients 
already treated, the probability is at least 70% that the risk is greater than 25%, we will consider 
stopping accrual pending feasibility evaluation. Starting from the 2nd patients, the stopping 
rules are shown in Table 2. 
 
Table 2.  Stopping rule for feasibility. 
Number of patients whose surgery is delayed 
for >28 days 
2 
3 
4 
5 
Out of this many patients 
2-4 
5-8 
9-11 
12 
 
Operating characteristics of the feasibility stopping rule are shown below and are based on 
5,000 simulatins: 
 
Risk of delayed surgery 
0.15 
0.20 
0.25 
0.30 
0.35 
0.40 
% of Time study stops 
17.3% 
29.3% 
43.1% 
56.2% 
68.3% 
79.2% 
Expected sample size 
10.8 
10 
9 
8.1 
7.1 
6.2 
 
 
We will report the proportion of patients experiencing high-grade toxicity with exact binomial 
95% confidence intervals. The safety analysis population includes patients who receive one 
dose of nivolumab. We will also describe patient experiences with respect to feasibility as 
defined above. The analysis population for feasibility includes patients who receive one dose of 
nivolumab. All other adverse events will be similarly summarized by type and grade. Analyses of 
immune markers will be descriptive and/or graphical in nature. 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 50 of 70 
 
 
Analysis of secondary endpoints 
 
We will obtain pathology reports from all surgical specimens and tabulate the data to obtain 
rate of pathologic CR. Descriptive reports of pathology findings for each cohort will also be 
reported. We will estimate progression-free survival probabilities using the Kaplan-Meier 
method. Progression-free survival is defined as the time from the first dose of nivolumab until 
progression or death from any cause.  Toxicities will be categorized by frequency and type, and 
reported in tabular form for each cohort and all subjects on the trial. All patients will be 
evaluable for toxicity from the time of their first treatment with any study therapy.   
 
11. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES  
(Please see lab manual for full details. The lab manual will be continually updated, and in case 
of discrepencies for specific items (e.g. a specific tube color) the lab manual will be followed as 
long as it is consistent with the intent of the protocol. 
 
Five categories of exploratory correlative immune responses will be analyzed:  
1) Expression of molecules in the tumor microenvironment (TME) via IHC and multispectral 
imaging of immunofluorescence staining (IF),  
2) Analysis of T cell responses in peripheral blood to mutation associated neoantigens (MANA) 
and HPV-16 E6 and E7,  
3) Flow cytometry and single cell analysis of TIL 
5) Genomic markers assessed via Exome sequencing and RNAseq used to assess MANA and 
HPV specific immune responses. 
 
Examples of membrane immunomodulatory molecules to be analyzed by IHC/IF as well as flow 
cytometry include, but are not limited to, PD-L1, PD-1, LAG3, TIM3, TIGIT, PVRIg. The 
neoadjuvant trial design also allows for the isolation of enough TIL to analyze coordinate 
expression of multiple membrane and intracellular molecules by multiparameter flow 
cytometry as a complement to IHC/IF. Multiparameter flow cytometry analysis of TIL will utilize 
a 25-color T cell staining panel that can be assessed on the BDnSymphony50, which currently 
simultaneously analyzes 28 colors and will have the capability to analyze 48 colors in 2019. 
Competing multiplex flow cytometers have achieved similar results (e.g. Cytek Aurora). In 
addition to cell membrane receptors and ligands, a number of transcriptional activators and 
repressors have been associated with the anergic or “exhausted” T cell functional state vs an 
active effector or effector-memory state. For example, Tbethi Eomeslo cells represent 
renewable effector memory cells where as TbetloEomeshi cells are terminal cells on their way 
to full exhaustion or apoptosis. Other more recently defined transcriptional regulators, such as 
TCF-1, are important in maintenance of effector function.  
 
Comprehensive genomic, transcriptomic and neoantigen analyses in tumor biopsies will be 
performed and MANA and HPV E6/7 antigen recognition will be analyzed via the MANAFEST 
assay for MANA and the VIRAFEST assay for HPV. Whole-exome sequencing utilizing the 
Personal Genome Diagnostics (PGDx) next-generation platform will be utilized and performed 
on pre-treatment and resected tumor samples. This will allow detection of mutations in DNA-

Johns Hopkins Protocol #: 
J1923  
 
Page 51 of 70 
 
repair and other relevant genes. Exome data will be applied in a neoantigen prediction pipeline 
that evaluates antigen processing, MHC binding and gene expression to generate neoantigens 
specific to the patient’s HLA haplotype. Truncal neoantigens will be identified by correcting for 
tumor purity and ploidy. Putative neoantigens will then be used to generate peptides and 
stimulate autologous T cells, followed by T Cell Receptor (TCR) next-generation sequencing 
(MANAFEST).  
 
The MANAFEST assay will determine if treatment increases the frequency and/or magnitude of 
anti-tumor T cell responses, based on the parameters described above. For each patient, the 
comparison of MANA-specific T cell clonality pre-and post-treatment among the peptides that 
are positive at both time points will be analyzed using a paired-sample t-test, and the difference 
of clonality of peptides that were MANAFEST-positive at either time points will be assessed 
using a mixed effect model to account for the correlation of common peptides. The analysis of 
MANAFEST results across patients will apply mixed effect models with each patient as a cluster, 
to account for the correlations due to the common microenvironment within a patient. Data 
transformation will be considered if the distribution of MANAFEST data is not normal. The 
VIRAFEST assay is an adaptation of the MANAFEST that analyzes T cell responses to predicted 
viral antigens in the identical fashion. For patients on this protocol with HPV+ HNSCC, we will 
analyze responses to a set of HPV-16 E6 and E7 peptides in addition to MANA peptides 
identified via WES. 
 
 
Collection of tumor tissue specimens 
 
 Collection of pretreatment tumor and/or lymph node biopsies 
 
Archived FFPE specimens from the original diagnostic tumor biopsy may be utilized. If archival 
tissue does not provide sufficient material for study, then new biopsies is recommended as 
clinically feasible. Ideally 6 (and at least 4) core needle biopsies of the tumor will be required at 
the time of diagnosis (prior to first dose of study drug) and in the event of a recurrence if 
clinically feasible; fine needle aspiration biopsy is sufficient for hilar or mediastinal lymph node 
sampling, but not for primary tumor biopsy. Where possible, and after a consent form has been 
signed, attempts will be made to coordinate diagnostic and study biopsies. 
 
Previously collected tissue/blood/material can be accessed for this study to fulfill study 
requirements including fresh/frozen/FFPE/etc biologic material to fulfill eligibility/study 
requirements. 
 
 Pretreatment biopsy handling, transportation, storage and processing 
 
Please see flow diagram in Appendix B for overview of tissue collection and the laboratory 
manual for detailed procedures. The study staff will be notified when a biopsy is taking place. 
The following procedures will be followed: 
 
If a core needle biopsy is being performed specifically for entry to the study, then at least four 

Johns Hopkins Protocol #: 
J1923  
 
Page 52 of 70 
 
(and ideally 6) core-biopsy specimens will be obtained, the first 3-4 of these cores obtained will 
be suspended in 10% buffered formalin while subsequent cores will be flash frozen in liquid 
nitrogen (see lab manual). After approximately 24 hours of suspension in formalin, the cores 
will be embedded in paraffin. As required for correlative analyses slides will be cut for the 
appropriate studies listed below. For fine needle aspiration biopsies of lymph nodes from 
bronchoscopy, cells will be collected by centrifugation, fixed in formalin and embedded in a 
paraffin block using standard pathology procedures. 
 
The study coordinator will keep a log with the study number, the patient’s study number, the 
date and time, and a consecutive sample number; thus, the samples will be numbered serially 
and will not contain identifying information. 
 
  Surgical specimens (tumor and lymph nodes) 
 
Tissue specimens obtained at the time of surgery will be dissociated enzymatically into single 
cell suspensions and will be viably cryopreserved according to a protocol provided in a 
companion laboratory manual. Additional specimens will fixed in formalin and embedded in 
paraffin blocks, for routine pathologic studies and immunohistochemistry. Tissue will also be 
flash-frozen at -80oC for subsequent RNA/DNA analysis. If there is additional tissue available, it 
will be embedded in OCT (Optimal Cutting Tissue) compound for analysis of frozen sections. 
 
  Collection of blood samples 
 
 Collection schedule 
 
Blood samples will be drawn and collected at the time points shown in the study calendar 
(section 4.10). These time points include: 
 
Day -28 (Prior to treatment): 100 mL whole blood or local protocol for collection accepted for 
peripheral blood mononuclear cell (PMBC) isolation, and 20 mL whole blood for serum isolation 
Day 0 (prior to surgery): 100 mL and 10 mL whole blood, for PBMCs and serum, respectively 
 
 Specimen handling, transportation, storage and processing 
 
 Serum samples: Whole blood will be collected in serum tubes, processed per 
manufacturer’s instructions and stored at -70°C or below until transfer for analysis. 
 
 PBMCs: Whole blood will be collected into EDTA tubes (Becton-Dickinson ETDA tube or 
equivalent) and processed per manufacturer’s instructions. Viable PBMCs will be stored 
in cryopreservation medium, at 5-10 ul per vial, in liquid nitrogen. 
 
Analysis of exploratory features of oral and gut microbiota that correlate with clinical 
response.  
 

Johns Hopkins Protocol #: 
J1923  
 
Page 53 of 70 
 
Integration of microbiome science into cancer therapeutics is a new field of study. Three recent 
papers published in Science have suggested that responses in melanoma and lung cancer are 
impacted by the composition of the microbiome and that certain bacterial species can promote 
improved therapeutic responses to checkpoint inhibitor therapy47-49 (). Thus, the goal of this 
sample collection is to facilitate exploratory, correlative analyses between the oral and gut 
microbiome communities and responses to neoadjuvant checkpoint blockade therapy.  
 
We will consider using 16S rRNA, shotgun metagenomics and/or RNA-seq for analyses. 16S 
rRNA sequencing data will be filtered for poor quality and contaminant/chimeric sequences, 
followed by taxonomic assignment using standard bioinformatic pipelines such as QIIME and 
Resphera Insight. To detect differentially abundant taxa between responders and non-
responders, we will utilize the nonparametric Mann-Whitney test with correction for multiple 
hypothesis testing using the False Discovery Rate. To evaluate beta-diversity between 
responders and non-responders (i.e. shared total community composition), we will compute 
the UniFrac distance metric for all sample pairs, followed by principal coordinate analysis and 
significance testing with PERMANOVA50. Functional inference of gene content from 16S rRNA 
data may also be performed using tools such as PICRUSt. While 16S rRNA identifies only 
bacterial sequences, metagenomics permits detection of viruses and fungi among others. 
Metagenomic analyses will be designed to remove human contaminant sequences followed by 
taxonomic assignment using Kraken and Pathoscope. Functional characterization of 
metagenomic data will be performed using the HUMAnN tool. Additionally, RNA-seq analysis 
(meta-transcriptomics) enables characterization of actively transcribed microbial genes and 
RNA viruses, with the potential to explore the combined host:microbial interaction(s).  
 
 Leftover samples 
 
Any leftover study blood and tissue samples will be stored in the Laboratories of 
coinvestigators at Johns Hopkins for future research studies. These samples may be released for 
use in future studies after approval by the principal investigator and other regulatory bodies, as 
appropriate. Subjects will be asked to consent to the future use of samples in the consent 
document. 
 
 
 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 54 of 70 
 
REFERENCES 
1. 
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11-30. 
2. 
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer 
J Clin 2011;61:69-90. 
3. 
Slebos RJ, Yi Y, Ely K, et al. Gene expression differences associated with human 
papillomavirus status in head and neck squamous cell carcinoma. Clinical cancer research : 
an official journal of the American Association for Cancer Research 2006;12:701-9. 
4. 
Stransky N, Egloff AM, Tward AD, et al. The mutational landscape of head and neck 
squamous cell carcinoma. Science 2011;333:1157-60. 
5. 
Agrawal N, Frederick MJ, Pickering CR, et al. Exome sequencing of head and neck 
squamous cell carcinoma reveals inactivating mutations in NOTCH1. Science 
2011;333:1154-7. 
6. 
McLaughlin-Drubin ME, Munger K. Oncogenic activities of human papillomaviruses. Virus 
Res 2009;143:195-208. 
7. 
Scheffner M, Huibregtse JM, Vierstra RD, Howley PM. The HPV-16 E6 and E6-AP complex 
functions as a ubiquitin-protein ligase in the ubiquitination of p53. Cell 1993;75:495-505. 
8. 
Dyson N, Howley PM, Munger K, Harlow E. The human papilloma virus-16 E7 oncoprotein 
is able to bind to the retinoblastoma gene product. Science 1989;243:934-7. 
9. 
Leemans CR, Braakhuis BJ, Brakenhoff RH. The molecular biology of head and neck cancer. 
Nat Rev Cancer 2011;11:9-22. 
10. Jordan RC, Lingen MW, Perez-Ordonez B, et al. Validation of methods for oropharyngeal 
cancer HPV status determination in US cooperative group trials. Am J Surg Pathol 
2012;36:945-54. 
11. Lingen MW, Xiao W, Schmitt A, et al. Low etiologic fraction for high-risk human 
papillomavirus in oral cavity squamous cell carcinomas. Oral Oncol 2013;49:1-8. 
12. Ang KK, Sturgis EM. Human papillomavirus as a marker of the natural history and response 
to therapy of head and neck squamous cell carcinoma. Semin Radiat Oncol 2012;22:128-
42. 
13. Ang KK, Harris J, Wheeler R, et al. Human papillomavirus and survival of patients with 
oropharyngeal cancer. The New England journal of medicine 2010;363:24-35. 
14. Marur S, D'Souza G, Westra WH, Forastiere AA. HPV-associated head and neck cancer: a 
virus-related cancer epidemic. Lancet Oncol 2010;11:781-9. 
15. Maier H, Dietz A, Gewelke U, Heller WD, Weidauer H. Tobacco and alcohol and the risk of 
head and neck cancer. Clin Investig 1992;70:320-7. 
16. Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of 
three nonsurgical treatment strategies to preserve the larynx in patients with locally 
advanced larynx cancer. Journal of clinical oncology : official journal of the American 
Society of Clinical Oncology 2013;31:845-52. 
17. Tan HK, Giger R, Auperin A, Bourhis J, Janot F, Temam S. Salvage surgery after concomitant 
chemoradiation in head and neck squamous cell carcinomas - stratification for postsalvage 
survival. Head & neck 2010;32:139-47. 
18. Fakhry C, Zhang Q, Nguyen-Tan PF, et al. Human papillomavirus and overall survival after 
progression of oropharyngeal squamous cell carcinoma. Journal of clinical oncology : 
official journal of the American Society of Clinical Oncology 2014;32:3365-73. 

Johns Hopkins Protocol #: 
J1923  
 
Page 55 of 70 
 
19. Guo T, Qualliotine JR, Ha PK, et al. Surgical salvage improves overall survival for patients 
with HPV-positive and HPV-negative recurrent locoregional and distant metastatic 
oropharyngeal cancer. Cancer 2015;121:1977-84. 
20. Joseph AW, Guo T, Hur K, et al. Disease-free survival after salvage therapy for recurrent 
oropharyngeal squamous cell carcinoma. Head & neck 2016;38 Suppl 1:E1501-9. 
21. Vermorken JB, Mesia R, Rivera F, et al. Platinum-based chemotherapy plus cetuximab in 
head and neck cancer. The New England journal of medicine 2008;359:1116-27. 
22. Strojan P, Corry J, Eisbruch A, et al. Recurrent and second primary squamous cell carcinoma 
of the head and neck: when and how to reirradiate. Head & neck 2015;37:134-50. 
23. Ishida Y, Agata Y, Shibahara K, Honjo T. Induced expression of PD-1, a novel member of the 
immunoglobulin gene superfamily, upon programmed cell death. The EMBO journal 
1992;11:3887-95. 
24. Schildberg FA, Klein SR, Freeman GJ, Sharpe AH. Coinhibitory Pathways in the B7-CD28 
Ligand-Receptor Family. Immunity 2016;44:955-72. 
25. Tseng SY, Otsuji M, Gorski K, et al. B7-DC, a new dendritic cell molecule with potent 
costimulatory properties for T cells. J Exp Med 2001;193:839-46. 
26. Latchman Y, Wood CR, Chernova T, et al. PD-L2 is a second ligand for PD-1 and inhibits T 
cell activation. Nat Immunol 2001;2:261-8. 
27. Dong H, Zhu G, Tamada K, Chen L. B7-H1, a third member of the B7 family, co-stimulates T-
cell proliferation and interleukin-10 secretion. Nat Med 1999;5:1365-9. 
28. Nishimura H, Nose M, Hiai H, Minato N, Honjo T. Development of lupus-like autoimmune 
diseases by disruption of the PD-1 gene encoding an ITIM motif-carrying immunoreceptor. 
Immunity 1999;11:141-51. 
29. Nishimura H, Okazaki T, Tanaka Y, et al. Autoimmune dilated cardiomyopathy in PD-1 
receptor-deficient mice. Science 2001;291:319-22. 
30. Saha A, O'Connor RS, Thangavelu G, et al. Programmed death ligand-1 expression on donor 
T cells drives graft-versus-host disease lethality. The Journal of clinical investigation 
2016;126:2642-60. 
31. Paterson AM, Brown KE, Keir ME, et al. The programmed death-1 ligand 1:B7-1 pathway 
restrains diabetogenic effector T cells in vivo. Journal of immunology (Baltimore, Md : 
1950) 2011;187:1097-105. 
32. Dong H, Strome SE, Salomao DR, et al. Tumor-associated B7-H1 promotes T-cell apoptosis: 
a potential mechanism of immune evasion. Nat Med 2002;8:793-800. 
33. Brahmer JR, Drake CG, Wollner I, et al. Phase I study of single-agent anti-programmed 
death-1 (MDX-1106) in refractory solid tumors: safety, clinical activity, pharmacodynamics, 
and immunologic correlates. Journal of clinical oncology : official journal of the American 
Society of Clinical Oncology 2010;28:3167-75. 
34. Topalian SL, Drake CG, Pardoll DM. Immune checkpoint blockade: a common denominator 
approach to cancer therapy. Cancer Cell 2015;27:450-61. 
35. Pardoll DM. The blockade of immune checkpoints in cancer immunotherapy. Nat Rev 
Cancer 2012;12:252-64. 
36. Topalian SL, Hodi FS, Brahmer JR, et al. Safety, activity, and immune correlates of anti-PD-1 
antibody in cancer. The New England journal of medicine 2012;366:2443-54. 
37. Ferris RL, Blumenschein G, Jr., Fayette J, et al. Nivolumab for Recurrent Squamous-Cell 

Johns Hopkins Protocol #: 
J1923  
 
Page 56 of 70 
 
Carcinoma of the Head and Neck. The New England journal of medicine 2016. 
38. Chow LQ, Haddad R, Gupta S, et al. Antitumor Activity of Pembrolizumab in Biomarker-
Unselected Patients With Recurrent and/or Metastatic Head and Neck Squamous Cell 
Carcinoma: Results From the Phase Ib KEYNOTE-012 Expansion Cohort. Journal of clinical 
oncology : official journal of the American Society of Clinical Oncology 2016. 
39. Mehra R, Seiwert TY, Mahipal A, et al. Efficacy and safety of pembrolizumab in 
recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC): Pooled 
analyses after long-term follow-up in KEYNOTE-012. Journal of Clinical Oncology 
2016;34:6012-. 
40. Bauml J, Seiwert TY, Pfister DG, et al. Pembrolizumab for Platinum- and Cetuximab-
Refractory Head and Neck Cancer: Results From a Single-Arm, Phase II Study. Journal of 
clinical oncology : official journal of the American Society of Clinical Oncology 
2017;35:1542-9. 
41. Uppaluri R, Winkler AE, Lin T, et al. Biomarker and Tumor Responses of Oral Cavity 
Squamous Cell Carcinoma to Trametinib: A Phase II Neoadjuvant Window-of-Opportunity 
Clinical Trial. Clinical cancer research : an official journal of the American Association for 
Cancer Research 2017;23:2186-94. 
42. Forde PM, Chaft JE, Smith KN, et al. Neoadjuvant PD-1 Blockade in Resectable Lung Cancer. 
The New England journal of medicine 2018. 
43. Killock D. Lung cancer: Anti-PD-1 therapy in the frontline. Nat Rev Clin Oncol 2016;13:715. 
44. Polo V, Pasello G, Frega S, et al. Squamous cell carcinomas of the lung and of the head and 
neck: new insights on molecular characterization. Oncotarget 2016;7:25050-63. 
45. Uppaluri R, Zolkind P, Lin T, et al. Neoadjuvant pembrolizumab in surgically resectable, 
locally advanced HPV negative head and neck squamous cell carcinoma (HNSCC). Journal of 
Clinical Oncology 2017;35:6012-. 
46. Ferris RL. LBA46 - An Open-label, Multicohort, Phase 1/2 Study in Patients With Virus-
Associated Cancers (CheckMate 358): Safety and Efficacy of Neoadjuvant Nivolumab. 
Annals of Oncology 2017;28:v605-v49. 
47. Routy B, Le Chatelier E, Derosa L, et al. Gut microbiome influences efficacy of PD-1-based 
immunotherapy against epithelial tumors. Science 2018;359:91-7. 
48. Gopalakrishnan V, Spencer CN, Nezi L, et al. Gut microbiome modulates response to anti-
PD-1 immunotherapy in melanoma patients. Science 2018;359:97-103. 
49. Matson V, Fessler J, Bao R, et al. The commensal microbiome is associated with anti-PD-1 
efficacy in metastatic melanoma patients. Science 2018;359:104-8. 
50. McArdle BH, Anderson MJ. Fitting multivariate models to community data: A comment on 
distance-based redundancy anlaysis. Ecology 2001;82(1):290-297 
51.   Stein JE, Lipson EJ, Cotrell TR et al. Pan-Tumor Pathologic Scoring of Response to PD-(L)1 
Blockade. Clin Cancer Res 2019   
 
 
 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 57 of 70 
 
 
 
 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 58 of 70 
 
Appendix A. ECOG Performance Status Scale 
 
Score 
Definition 
0 
Asymptomatic 
1 
Symptomatic, fully ambulatory 
2 
Symptomatic, in bed less than 50% of day 
3 
Symptomatic, in bed more than 50% of day, but not bedridden 
4 
Bedridden 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 59 of 70 
 
Appendix B. Guidelines for Tissue Banking Process (may be modified based on guidelines in 
correlative SOP, which will be continually updated) 
 
Note: Only tissue that is absolutely not needed for clinical diagnosis or staging should be 
collected for tissue banking. If in doubt about this, do NOT submit specimens for banking. 
 
Banking of Frozen Tissue 
 
1. Place a single tissue specimen flat in the plastic bag. A single tissue specimen's 
overall volume should be at least 1 cm3, and at most 3–4 cm3, with at least one 
dimension measuring 0.5 cm thick or less to facilitate quick freezing.  
2. For a given case (patient), please collect sufficient non-malignant and malignant 
tissue. Tissue selected should be grossly viable, and grossly consistent with tumor or 
adjacent normal tissue (see #5 below for contraindications). Non-malignant (i.e. 
"adjacent normal") tissue should be collected at least 2 cm from the primary tumor, 
subject to any limitations from the specimen's physical dimensions. Do not place 
tumor and non-malignant tissue in the same bag. For large tumors, do not place 
large pieces of tissue in a single bag. Rather, divide the tissue according to size 
guidelines in #1 above, and place each in an individual bag. Collect and separately 
identify both: 1) primary tumor and 2) metastatic lesions to lymph nodes or other 
tissues. Tissue will typically be taken by scalpel or dissection blade, though the use of 
5 -7 mm skin punch biopsy tools could be considered in certain situations. 
3. Immediately place the specimens for freezing in an isopentane or 2-methylbutane 
cryobath, or other effective liquid freezing agent. If no cryobath is available, then 
liquid N2 can be used as the freezing agent, in a properly insulated container and 
with sufficient safety precautions. The goal is to have bankable tissue immersed in 
the bath within 30 minutes of the OR's procurement from the patient. If more 
cryobath space is needed, move already frozen tissue to a -80C freezer in order to 
make sufficient room. Make sure to check periodically for cryobath problems (e.g. 
not maintaining temperature, refrigerant level low), and call for appropriate 
maintenance as needed. Do not freeze tissue by placing it fresh directly in the -80C 
freezer. 
4. On receipt by the tissue bank laboratory, the frozen tissue is embedded in OCT 
(Optimal Cutting Temperature medium), and a frozen section is stained with H&E 
and the section evaluated by the tissue bank pathologist for quality assurance (QA) 
purposes. A report on the histopathologic findings is filed or communicated as 
needed. The frozen section evaluation can also count for adjacent pieces of tissue if 
they were taken as a "mirror image" section to the surface cut for the frozen 
section. 
5. General contraindications to tissue banking 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 60 of 70 
 
DON'T bank tissue from these specimen types or situations: 
 
 small tumors and other cases where all or most of the lesional tissue is needed for 
diagnosis 
 
 surgical margins of resection specimens where tumor and benign areas cannot be 
clearly delineated grossly grossly visible areas of primarily necrosis, hemorrhage, or fat 
 
 specimens which are known to have been delayed significantly more than 30 minutes 
past their procurement time in the OR 
 
 tissue previously freeze-thawed, or frozen slowly (e.g. in the cryostat or -80 freezer) 
 
 areas of deepest invasion, tumor/normal interface, tumor/capsule interface, extranodal 
extension of tumor, and other key landmarks needed for surgical pathology evaluation 
and/or tumor staging 
 
 diagnostic biopsies where most or all tissue must be submitted for pathology 
evaluation: most lymph node, GI, bone marrow, and liver biopsies fall in this category 
 
 tissue clearly marked as intended for a special study such as immunofluorescence 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 61 of 70 
 
Appendix C. Immune-Related Adverse Events Management Algorithms 
 
These general guidelines constitute guidance to the Investigator and may be supplemented by 
discussions with the Principal Investigator. The guidance applies to all immuno-oncology agents 
and regimens. 
 
A general principle is that differential diagnoses should be diligently evaluated according to 
standard medical practice and SITC or ASCO irAE management guidelines should be consulted . 
Non-inflammatory etiologies should be considered and appropriately treated. 
 
Corticosteroids are a primary therapy for immuno-oncology drug-related adverse events. The 
oral equivalent of the recommended IV doses may be considered for ambulatory patients with 
llow-grade toxicity. The lower bioavailability of oral corticosteroids should be taken into 
account when switching to the equivalent dose of oral corticosteroids. 
 
Consultation with a medical or surgical specialist, especially prior to an invasive diagnostic or 
therapeutic procedure, is recommended. 
 
The frequency and severity of the related adverse events covered by these algorithms will 
depend on the immuno-oncology agent or regimen being used. 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 62 of 70 
 
Appendix D: Sociodemographic questionaires (Initial and follow-up) 
 
Initial Sociodemographic Characteristics Questionnaire 
Date:  Month_____ / Day ______ / Year______ 
Study ID Number:  _______________________ 
Medical Records Number: _________________ 
 
SOCIODEMOGRAPHIC CHARACTERISTICS QUESTIONNAIRE 
 
1. Name: 
___________________________________________________ 
 
2. Birthdate: 
month ______/day ___________/year ________ 
 
3. Sex: 
 Male 
Female 
 
4. What is your race or ethnic group? 
 Caucasian  Hispanic 
 African American 
 
 Asian 
 Other _____________________ 
 
 I choose not to disclose 
FAMILY QUESTIONS 
 
Both genetics and environment could be risk factors for the development of cancer. For this 
reason, it is important to determine your biological relationship with your family. 
 
5. Are you adopted? □ Yes □ No 
6. How many of each of the following family members do you have? 
Brothers: __________Sisters: __________Sons: __________ Daughters: _________ 
SMOKING QUESTIONS 
 
7. Do you smoke cigarettes?                                                             Yes 
 No, never 
  Not currently but I have in the 
past 
8. At what age did you start smoking? 
_________ 
 
9. When did you quit smoking cigarettes? _________ 
 
10. How many total years have you or did you regulary smoke cigarettes? __________________ 
 
11. During the time you usually smoked regularly, how many cigarettes do or did you usually 
smoke per day?   _________ 
 
12. Do you smoke cigars?            □ Yes □ No, never □ Not currently but I have in the Past 
 
13. At what age did you start smoking cigars?  ________ 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 63 of 70 
 
14. When did you quit smoking cigars? _________ 
 
15. How many years in total did you regularly smoke cigars? ___________ 
 
16.  Do you use smokeless tobacco or other nicotine products? (i.e. chewing tobacco, snuff, e-
cigarette, nicotine patch or gum)                        
 
 Yes            No 
 
If yes, please indicate type(s):_________________________________________________ 
 
17. Were you exposed to asbestos, that you know of?                           Yes 
     No 
 
18. Were you exposed to any other potential harmful exposures to your lung?  
 
 
 
                           Yes              No/never 
 
ALCOHOL QUESTIONS 
 
19. Have you ever drunk alcoholic beverages, such as beer, wine, or liquor regularly, that is at 
least once a month? 
 Yes 
 No 
 
20. At what age did you start drinking alcoholic beverages regularly, i.e. at least once a month? 
 
__________________years of age 
 
21. Before the age of 40, how many drinks of beer (12 oz.), wine (5oz.), or liquor (1 oz.) did you 
usually drink per week? 
More than one per week. Please indicate number_________________ 
Less than one per week_________________ 
Never drank before age 40 _________ 
 
22. After the age of 40, how many drinks of beer (12 oz.), wine (5 oz.), or liquor (1 oz.) did you 
usually drink per week? 
More than one per week. Please indicate number ________________ 
Less than one per week ___________ 
Never drank after age 40 __________ 
Currently aged less than 40 years __________ 
 
MEDICAL QUESTIONS 
  23. Have you taken antibiotics in the last 3 months?     Yes          No 
     A list of antibiotics is attached for you to refer to. If no, skip to question 25. 
 
24. If you know the name of the antibiotic(s), please write it here. 
___________________________________________________________________________
___________________________________________________________________________ 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 64 of 70 
 
25. Have you had a bronchoscopy in the last 3 months?     
  Yes        No 
 
26. Have you taken oral corticosteroids in the last 2 weeks?   
 Yes         No 
(Oral 
corticosteroids 
examples: 
prednisone, 
dexamethasone, 
methlyprednisone, 
hydrocortisone) 
 
27. If you answered Yes to (26), please write the name and dose here and when you took these. 
______________________________________________________________________________
______________________________________________________________________________ 
 
28. Have you taken inhaled corticosteroids in the last 2 weeks?     Yes         No 
(Inhaled corticosteroids examples: budesonide, fluticasone, beclomethasone, ciclesonide) 
 
29. If you answered Yes to (28), please write the name and dose here and when you took these. 
______________________________________________________________________________
______________________________________________________________________________ 
 
30.Do you have sleep apnea?     Yes         No 
 
31.Do you have reflux disease?    Yes         No 
 
32.Do you have any other chronic lung conditions?      Yes        No 
 
33. If you answered Yes to (32), please write the name of the condition here 
______________________________________________________________________________
______________________________________________________________________________ 
 
DENTAL HEALTH 
 
34.  About how often do you visit a dentist? 
 
 Less than every 6 months. 
 
 Between every 6-12 months. 
 
 Greater than every 12 months. 
 
 I have never been to a dentist. 
 
35. 
 
Overall, 
how 
would 
you 
rate the 
health 
of 
your 
teeth 
and 
gums?                           
 Excellent                                Good                                       Fair                                          Poor                          
 
36.  Have you ever had treatment for gum disease such as scaling and root planing, sometimes 
called deep cleaning?                                                                                    Yes 
 No 
 
37.  Have you ever had any teeth become loose on their own, without an injury?  (Not including 
baby teeth).                                                                                                   Yes 
 No 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 65 of 70 
 
DIET QUESTIONS 
 
38. Do you eat meat? Meat is defined as beef, chicken, pork, lamb or venison: 
A. I do not eat meat.  
 
 
 
 
 
 
 
 
B. I have eaten meat in the last year.   
 
 
 
 
 
C. I have eaten meat one or more times a month during the last year.  
 
D. I have eaten meat one or more times a week during the last year.  
 
 
39. Do you eat Fish? Fish is defined as all fish and shellfish: 
A. I do not eat fish.  
 
 
 
 
 
 
 
 
B. I have eaten fish in the last year.  
 
 
 
 
 
 
C. I have eaten fish one or more times a month during the last year.  
 
D. I have eaten fish one or more times a week during the last year  
 
 
 
40. Do you eat Eggs? 
 
A. I do not eat eggs 
  
 
B. I have eaten eggs in the last year 
  
 
C. I have eaten eggs one or more times a month during the last year 
  
 
D. I have eaten eggs one or more times a week during the last year                
 
41. Do you eat Cheese?  (This includes fresh, soft, aged or cottage cheese as well as sour cream): 
 
A. I do not eat cheese 
  
 
B. I have eaten cheese in the last year 
  
 
C. I have eaten cheese one or more times a month during the last year 
  
 
D. I have eaten cheese one or more times a week during the last year 
  
 
42. Do you drink Milk? Milk is defined as milk from a cow, goat or sheep (not soy, coconut or 
almond milk, for example).  If you put milk on your cereal, you should not answer (A). 
 
A. I do not drink milk 
 
 
B. I drank milk in the last year 
 
 
C. I drank milk one or more times a month during the last year 
 
 
D. I drank milk one or more times a week during the last year 
 
 
43. Do you eat yogurt? 
 
 
A. I do not eat yogurt 
  
 
B. I have eaten yogurt in the last year 
  
 
C. I have eaten yogurt one or more times a month during the last year 
  
 
D. I have eaten yogurt one or more times a week during the last year   
 
 
44. Do you take probiotics (live bacteria supplement)? 
 Yes 
 No 
 
If yes (question 44) and if you know the name of the probiotic product(s), please write here: 
___________________________________________________________________________ 
 
___________________________________________________________________________ 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 66 of 70 
 
45. Do you take vitamin supplements? 
 Yes 
 No 
If yes (question 45) and if you know the name of the vitamin supplement(s), please write 
it/them here:  
___________________________________________________________________________
___________________________________________________________________________ 
 
WORK AND PHYSICAL ACTIVITY 
 
46. What is your current employment status? 
□ Employed/self-employed     □ Unemployed     □ Retired     □ Disabled 
 
47. How would you categorize your physical activity on the job? 
□ Mostly sedentary or light activity (e.g. mostly sitting, standing, lifting light objects of less 
than 3 kilos). 
□ Mostly medium activity (e.g. much walking, climbing stairs). 
□ Mostly intense activity (e.g. heavy construction work). 
□ Unemployed/retired/disabled 
 
48. What type of exercise (physical activity) do you do regularly (at least 3 times per week)? 
□ Mostly moderate activity (slow walking, gardening, golfing etc.) 
□ Mostly vigorous activity (running, swimming, bicycling, football etc.) 
□ I do not exercise regularly 
 
49. At age 20, what type of exercise did you do regularly (at least 3 times per week)? 
□ Mostly moderate activity (slow walking, gardening, golfing etc.) 
□ Mostly vigorous activity (running, swimming, bicycling, football etc.) 
□ I did not exercise regularly 
 
 
 
 
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 67 of 70 
 
Follow-Up Sociodemographic Characteristics Questionnaire  
 Date: Month_____ / Day ______ / Year______  
Study ID Number: _______________________  
   Medical Records Number: ________________  
SMOKING QUESTIONS  
1. Are you currently smoking?   Yes          No  
If yes, how many cigarettes/day?_________  
ALCOHOL QUESTIONS  
2. Regularly?  Yes          No  
If yes, please indicate pattern:  
More than one per week_______  (If checked), please indicate number____________  
Less than one per week_______  
 
MEDICAL QUESTIONS  
3. Have you taken antibiotics since completing the last questionnaire? Yes   No  
4. If you know the name of the antibiotic(s), please write it here. 
___________________________________________________________________________ 
___________________________________________________________________________  
A list of antibiotics is attached for you to refer to. If no, skip to question 5.  
5. Have you had a bronchoscopy since completing the last questionnaire? Yes   No  
6. Have you taken oral corticosteroids since completing the last questionnaire? Yes   No 
(Oral corticosteroids examples: prednisone, dexamethasone, methlyprednisone, 
hydrocortisone)  
7. If you answered Yes to (6), please write the name and dose here and when you took these. 
______________________________________________________________________________ 
______________________________________________________________________________  

Johns Hopkins Protocol #: 
J1923  
 
Page 68 of 70 
 
8. Have you taken inhaled corticosteroids since completing the last questionnaire?  
Yes No (Inhaled corticosteroids examples: budesonide, fluticasone, beclomethasone, 
ciclesonide)  
9. If you answered Yes to (8), please write the name and dose here and when you took these. 
______________________________________________________________________________ 
______________________________________________________________________________  
 
 
10. Do you eat meat? Meat is defined as beef, chicken, pork, lamb or venison:  
A. I do not eat meat.   
 
 
 
 
 
 
 
 
 
B. I have eaten meat in the last year.





 
C. I have eaten meat one or more times a month during the last year.  
 
 
 
D. I have eaten meat one or more times a week during the last year.  
 
 
 
 
11. Do you eat Fish? Fish is defined as all fish and shellfish: 
A. I do not eat fish.   
 
 
 
 
 
 
 
 

B. I have eaten fish in the last year.   
 
 
 
 
 
 

C. I have eaten fish one or more times a month during the last year.  
 
 

D. I have eaten fish one or more times a week during the last year  
 
 
 
 
12. Do you eat Eggs? 
A. I do not eat eggs   
 
 
 
 
 
 
 
 

B. I have eaten eggs in the last year   
 
 
 
 
 
 

C. I have eaten eggs one or more times a month during the last year  
 
 

D. I have eaten eggs one or more times a week during the last year  
 
 

 
13. Do you eat Cheese? (This includes fresh, soft, aged or cottage cheese as well as sour 
cream):  
A. I do not eat cheese  
 
 
 
 
 
 
 
 

B. I have eaten cheese in the last year 
 
 
 
 
 
 

C. I have eaten cheese one or more times a month during the last year   
 

D. I have eaten cheese one or more times a week during the last year  
 
 
 
 
14. Do you drink Milk? Milk is defined as milk from a cow, goat or sheep (not soy, coconut or 
almond milk, for example). If you put milk on your cereal, you should not answer (A). 
A. I do not drink milk  
 
 
 
 
 
 
 
 

B. I drank milk in the last year  
 
 
 
 
 
 
 
 
C. I drank milk one or more times a month during the last year   
 
 

D. I drank milk one or more times a week during the last year  
 
 
 

DIET QUESTIONS  

Johns Hopkins Protocol #: 
J1923  
 
Page 69 of 70 
 
 
15. Do you eat yogurt? 
A. I do not eat yogurt  
 
 
 
 
 
 
 
 

B. I have eaten yogurt in the last year  
 
 
 
 
 
 

C. I have eaten yogurt one or more times a month during the last year   
 

D. I have eaten yogurt one or more times a week during the last year  
 
 
 
 
16. Do you take probiotics (live bacteria supplement)? Yes     No  
If yes (question 16) and if you know the name of the probiotic product(s), please write here: 
___________________________________________________________________________ 
___________________________________________________________________________  
17. Do you take vitamin supplements? Yes.   No  
If yes (question 17) and if you know the name of the vitamin supplement(s), please write 
it/them here: 
___________________________________________________________________________ 
___________________________________________________________________________  
 
WORK AND PHYSICAL ACTIVITY  
18. What type of exercise (physical activity) do you do regularly (at least 3 times per week)?  
    Mostly moderate activity (slow walking, gardening, golfing etc.)  
    Mostly vigorous activity (running, swimming, bicycling, football etc.)  
I do not exercise regularly  
 
 

Johns Hopkins Protocol #: 
J1923  
 
Page 70 of 70