A Randomized Phase II Trial of Carboplatin With or Without Nivolumab in First-line Metastatic Triple-negative Breast Cancer
Phase: PHASE2
Conditions: Breast Cancer
Sponsor: Dana-Farber Cancer Institute

1
DF/HCC Protocol #: 17-512 
TITLE:  A randomized phase II trial of carboplatin with or without nivolumab in first-line 
metastatic triple-negative breast cancer
Coordinating Center:
Dana-Farber/Partners Cancer Care (DF/PCC) on behalf of 
Dana Farber/Harvard Cancer Center
*Principal Investigator (PI):
Sara Tolaney, MD, MPH
 
Other Investigators:
 
 
Statistician:
Project Manager: 
      
      
IND #: 136600  
IND Sponsor:  Sara Tolaney, MD, MPH
Protocol Type / Version # / Version Date:
Amendment 4/Version 3/02.02.21

DF/HCC Protocol #:17-512
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SCHEMA
  

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TABLE OF CONTENTS
SCHEMA
2
1.
OBJECTIVES6
1.1
Study Design...............................................................................................................6
1.2
Primary Objectives......................................................................................................6
1.3
Secondary Objectives..................................................................................................6
1.4
Correlative Objectives ................................................................................................7
2.
BACKGROUND .................................................................................................................8
2.1
Overview of Triple-Negative Breast Cancer and Current Options.............................8
2.2
The PD-1/PD-L1 pathway in cancer.........................................................................11
2.3
Rationale for Crossover Amendment and Clinical Trial Implications .....................13
2.4
Nivolumab.................................................................................................................14
2.5
Carboplatin................................................................................................................19
2.6
Combination of Carboplatin and Nivolumab............................................................21
2.7
Correlative Studies Background ...............................................................................28
3.
PARTICIPANT SELECTION...........................................................................................30
3.1
Eligibility Criteria.....................................................................................................30
3.2
Exclusion Criteria .....................................................................................................33
4.
REGISTRATION PROCEDURES ...................................................................................35
4.1
General Guidelines for DF/HCC Institutions ...........................................................35
4.2
Registration Process for DF/HCC Institutions..........................................................35
4.3
General Guidelines for Other Investigative Sites .....................................................35
4.4
Registration Process for Other Investigative Sites....................................................35
5.
TREATMENT PLAN........................................................................................................36
5.1
Treatment Regimen...................................................................................................36
5.2
Pre-Treatment Criteria ..............................................................................................37
5.3
Agent Administration................................................................................................37
5.4
Definition of Dose-Limiting Toxicity (DLT) ...........................................................39
5.5
Definition of Potential Drug Induced Liver Injury (DILI) .......................................40
5.6
General Concomitant Medication and Supportive Care Guidelines.........................41
5.7
Criteria for Taking a Participant Off Protocol Therapy............................................43
5.8
Duration of Follow-Up .............................................................................................47
5.9
Criteria for Taking a Participant Off Study ..............................................................47
6.
Dosing Delays/Dose modifications....................................................................................47
6.1
Dosing Delays/Omission/Modifications...................................................................48
6.2
Management of Toxicities Attributable to Nivolumab.............................................51
6.3
Management of Toxicities Attributable to Carboplatin............................................63
6.4
Management of Toxicities Attributable to nab-Paclitaxel Alone .............................70

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7.
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................77
7.1
Adverse Events List..................................................................................................77
7.2
Adverse Event Characteristics..................................................................................79
7.3
Expedited Adverse Event Reporting.........................................................................80
7.4
DF/HCC Expedited Reporting Guidelines................................................................80
7.5
Expedited Reporting to the Food and Drug Administration (FDA) .........................81
7.6
Expedited Reporting to Hospital Risk Management ................................................81
7.7
Expedited Reporting to
....................................................................................81
7.8
Routine Adverse Event Reporting ............................................................................83
8.
PHARMACEUTICAL INFORMATION..........................................................................83
8.1
Nivolumab.................................................................................................................83
8.2
Carboplatin................................................................................................................85
8.3
Nab-Paclitaxel...........................................................................................................86
9.
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................88
9.1
Archival Tissue.........................................................................................................91
9.2
Fresh Tissue Biopsy..................................................................................................91
9.3
Blood Collection.......................................................................................................99
9.4
Stool Collection ......................................................................................................103
9.5
Diet and Physical Activity Assessments.................................................................104
9.6
Central Confirmation of PD-L1 Status ...................................................................105
9.7
Additional analyses.................................................................................................105
10.
STUDY CALENDAR .....................................................................................................105
11.
MEASUREMENT OF EFFECT .....................................................................................111
11.1 Antitumor Effect – Solid tumors.............................................................................111
11.2 Other Response Parameters ....................................................................................118
12.
DATA REPORTING / REGULATORY REQUIREMENTS.........................................120
12.1 Data Reporting........................................................................................................121
12.2 Data Safety Monitoring...........................................................................................121
12.3 Multicenter Guidelines............................................................................................121
12.4 Collaborative Research and Future Use of Data and Samples ...............................121
13.
STATISTICAL CONSIDERATIONS.............................................................................122
13.1 Study Design/Endpoints .........................................................................................122
13.2 Sample Size, Accrual Rate and Study Duration .....................................................123
13.3 Stratification Factors for Secondary Analyses........................................................123
13.4 Interim Monitoring Plan .........................................................................................124
13.5 Analysis of Primary Endpoint.................................................................................124
13.6 Analysis of Secondary Endpoints...........................................................................125
13.7 Correlative endpoints..............................................................................................125
13.8 Reporting and Exclusions .......................................................................................128
14.
PUBLICATION PLAN ...................................................................................................129

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15.
REFERENCES ................................................................................................................130
APPENDIX A
PERFORMANCE STATUS CRITERIA ................................................139
APPENDIX B
MULTI-CENTER DATA and Safety Monitoring Plan...........................140
APPENDIX C
DIET AND PHYSICAL ACTIVITY ASSESSMENTS ...........................12
APPENDIX D
DIET AND PHYSICAL ACTIVITY ASSESSMENTS ...........................16

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1. OBJECTIVES
1.1
Study Design
This is an open-label, multi-institutional, randomized phase II trial of carboplatin given 
intravenously at AUC 6 on day 1 of every 21-day cycle, alone or in combination with 
nivolumab given intravenously at 360 mg on day 1 of every 21-day cycle, in subjects 
with metastatic triple-negative breast cancer (TNBC) treated with 0 prior lines of therapy 
in the metastatic setting. 
1.2
Primary Objectives
To compare the efficacy of carboplatin in combination with nivolumab versus carboplatin 
alone, as defined by progression-free survival (PFS), as first-line therapy in the metastatic 
setting for patients with unselected (by PD-L1 status) metastatic TNBC.
1.3
Secondary Objectives
Efficacy objectives

To compare the efficacy of carboplatin in combination with nivolumab versus carboplatin 
alone, as defined by overall response rate (ORR) according to RECIST 1.1 (1) and 
immune-related response criteria (irRC)(2), in patients with unselected metastatic TNBC.

To compare the efficacy of carboplatin in combination with nivolumab versus carboplatin 
alone, as defined by overall survival (OS), in patients with unselected metastatic TNBC.

To compare the efficacy of carboplatin in combination with nivolumab versus carboplatin 
alone, as defined by clinical benefit rate (CBR) according to RECIST 1.1, in patients with 
unselected metastatic TNBC. 

To evaluate the duration of response (DOR) and time to objective response (TTOR) of 
carboplatin in combination with nivolumab versus carboplatin alone, in patients with 
unselected metastatic TNBC.

To compare the efficacy of carboplatin in combination with nivolumab versus carboplatin 
alone, as defined by PFS, ORR according to RECIST 1.1 and irRC, CBR, DOR, TTOR 
and OS, in patients with PD-L1-positive metastatic TNBC (defined as ≥1% of the tumor 
cell population demonstrating unequivocal staining for PD-L1).

To explore the efficacy of carboplatin alone or in combination with nivolumab, in terms 
of PFS, ORR according to RECIST 1.1 and irRC, CBR, DOR, TTOR and OS, for 
metastatic TNBC in patients with germline BRCA1 or BRCA2 mutations.

To explore the efficacy of nab-paclitaxel in combination with nivolumab, in terms of 
PFS, ORR according to RECIST 1.1 and irRC, CBR, DOR, TTOR and OS, as second-
line therapy in patients with metastatic TNBC who crossover after progression on 
carboplatin alone, and explore outcomes by PD-L1 status.

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Safety objectives

To evaluate the safety and tolerability of carboplatin in combination with nivolumab, and 
compare to that of carboplatin alone, in patients with metastatic TNBC previously treated 
with 0 lines of chemotherapy in the metastatic setting.

To evaluate the safety and tolerability of nab-paclitaxel in combination with nivolumab, 
as second-line therapy in patients with metastatic TNBC who crossover after progression 
on carboplatin alone.
1.4
Correlative Objectives
1.4.1
To explore tissue biomarkers of antitumoral immune activity and tumor genomic 
instability as predictors of response, or resistance, to carboplatin plus nivolumab, 
compared to carboplatin alone, in patients with metastatic TNBC.

To characterize tumor-infiltrating lymphocytes (TILs), by histological assessment, 
at baseline and correlate with disease response to treatment (PFS, objective 
response assessed by RECIST 1.1 and irRC, OS).

To characterize the expression of markers of immune cell subsets (i.e. CD8 for 
cytotoxic T cells, CD68 for macrophages), inhibitory checkpoint pathway 
molecules (i.e. PD-1, PD-L1, TIM3, LAG3), and co-stimulatory pathway molecules 
(i.e. GITR, OX40) by immunohistochemistry (IHC) and/or immunofluorescence 
(IF).

To explore whether immunosuppressive and/or immune-stimulating immune 
marker profiles at baseline correlate with disease response to treatment (PFS, 
objective response assessed by RECIST 1.1 and irRC, OS).

To characterize mutational load and neoantigen burden at baseline and correlate 
with disease response to treatment (PFS, objective response assessed by RECIST 
1.1 and irRC, and OS).

To characterize RNA expression signatures of immune pathway activation and 
DNA damage repair deficiency at baseline and correlate with disease response to 
treatment (PFS, objective response assessed by RECIST 1.1 and irRC, and OS).

To explore whether changes in TILs, immunosuppressive and/or immune-
stimulating immune marker profiles, mutational load, neoantigen burden, and RNA 
expression signatures, between paired biopsies from baseline and after 2 cycles of 
treatment, correlate with disease response to treatment (PFS, objective response 
assessed by RECIST 1.1 and irRC, OS).

To explore mechanisms of resistance to carboplatin plus nivolumab, compared to 
carboplatin alone, in paired biopsies from baseline and at time of progression.

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1.4.2
To explore blood biomarkers of antitumoral immune activity as predictors of response, or 
resistance, to carboplatin plus nivolumab, compared to carboplatin alone, in patients with 
metastatic TNBC.

To characterize serial changes in immune marker profile in peripheral blood 
mononuclear cells (PBMCs) and in plasma over the course of study treatment.

To explore whether induction of changes in the immunosuppressive and/or 
immune-stimulating immune marker profile in PBMCs correlates with disease 
response to therapy (PFS, objective response assessed by RECIST 1.1 and irRC, 
OS).

To investigate whether there is an immune marker (i.e. PD-L1) in circulating 
PBMCs that correlates to tumor infiltrating lymphocyte (TIL) percentage in 
baseline tumor.

To characterize serial changes of neoantigen burden in circulating tumor DNA and 
correlate with disease response to treatment (PFS, objective response assessed by 
RECIST 1.1 and irRC, OS).

To explore serial changes in blood biomarkers as mechanisms of resistance to 
carboplatin plus nivolumab, compared to carboplatin alone.
1.4.3
To explore the structure and function of the gut microbiome as predictors of response, or 
resistance, to carboplatin plus nivolumab, compared to carboplatin alone, in patients with 
metastatic TNBC.

To characterize structure and function of the gut microbiome at baseline and 
correlate with disease response to treatment (PFS, objective response assessed by 
RECIST 1.1 and irRC, OS).

To explore whether changes in the overall diversity of gut microbiome, estimated 
by Shannon index, correlate with disease response to treatment (PFS, objective 
response assessed by RECIST 1.1 and irRC, OS).

To explore mechanisms of resistance to carboplatin plus nivolumab, compared to 
carboplatin alone, in paired samples from baseline and at time of progression.

To explore correlations between diversity and taxa of the gut microbiome and 1) 
diet composition, 2) physical activity patterns, and 3) body mass index (BMI). 
1.4.4
To explore tissue, blood and microbiome biomarkers as predictors of response, or 
resistance, to nab-paclitaxel plus nivolumab, in patients with metastatic TNBC who 
crossover after progression on carboplatin alone.
1.4.5
To explore the relationship between response to carboplatin plus nivolumab and diet 
composition, physical activity patterns and body mass index.  
2. BACKGROUND
2.1
Overview of Triple-Negative Breast Cancer and Current Options
Breast cancer is the most frequently diagnosed cancer and the second cause of cancer death 
in women in the Unites States(3). The heterogeneity of breast cancer has been widely demonstrated 
by gene expression profiling, distinguishing intrinsic subtypes including luminal A, luminal B, 

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epidermal growth factor receptor type 2 (EGFR2, ERBB2 or HER2)-enriched, basal-like and 
claudin-low breast subtypes, with different prognostic and therapeutic  implications for each 
type(4). Breast tumors that are immunohistochemically characterized by the lack of expression of 
estrogen receptor (ER), progesterone receptor (PR) and HER2, are classified as triple negative 
breast cancer (TNBC), accounting for 15-20% of all breast cancers(5). Despite the fact that most 
immunohistochemically defined TNBC (75%) have a basal-like phenotype according to gene 
expression, triple-negative tumors can less commonly fall into any of the other intrinsic subtypes. 
However, considering the overlap between both classifications, for daily clinical practice, TNBC 
is assumed to be equivalent to basal-like breast cancer.
TNBC has a highly aggressive clinical course, with an earlier age of onset, greater metastatic 
potential and poorer clinical outcomes, in terms of survival and higher rates of local relapse, 
compared to patients with receptor-positive cancers. Studies of neoadjuvant chemotherapy suggest 
that women with TNBC who obtain pathological complete response (pCR) with treatment achieve 
excellent outcomes(6). In addition, in patients with TNBC, pCR rates have been proven to correlate 
with higher scores of tumor-infiltrating lymphocytes (TIL)(7, 8). Unfortunately, residual disease 
is present in the majority of patients with early-stage TNBC treated with neoadjuvant 
chemotherapy, increasing the risk of relapse, predominantly in the first 3 years after treatment(6). 
Consequently, an elevated proportion of patients eventually develop visceral or central nervous 
system (CNS) metastases and treatment options are limited in these patients because standard 
chemotherapeutic regimens containing anthracyclines and taxanes have usually already been used 
in the neo-/adjuvant setting. After taxane- and anthracycline-based treament, there is no standard 
regimen for metastatic TNBC. With chemotherapy strategies selected from a number of currently 
recommended agents, ORR range from 26-48% in first-line TNBC, with a usually short duration 
of response, rapid relapse and median survival of 13-18 months(9).
Anthracyclines and taxanes have been suggested as rechallenge regimens in patients that relapse 
at least 6 to 12 months following completion of adjuvant chemotherapy. However, their use is 
often limited due to concerns of increased toxicity and, in the case of anthracyclines, exceeding 
cumulative dose levels. Moreover, there are few data to support this strategy in first- or second-
line treatment for metastatic breast cancer. To date, one prospective phase III trial comparing 
docetaxel or pegylated liposomal doxorubicin (PLD) followed by docetaxel demonstrated a 
significant improvement in time to progression (median 7.0 vs. 9.8 months, respectively) and ORR 
(26% vs. 35%, respectively) favoring the combination arm(10). However, in subgroup analyses, 
PFS improvement was not statistically significant in the TNBC subtype.
Several chemotherapy regimens are felt to be appropriate, as single agents or in combination, for 
the treatment of metastatic TNBC. Although combination regimens generally provide higher rates 
of objective response and improved PFS, combination chemotherapy has been associated with 
increased toxicity and marginal overall survival (OS) benefit(11-13). Among preferred single 
agents, consensus guidelines include antimetabolites (capecitabine, gemcitabine), taxanes 
(docetaxel, paclitaxel or albumin-bound paclitaxel) and non-taxane microtubule inhibitors 
(vinorelbine and eribulin)(14). A recent phase III trial compared eribulin with capecitabine in 
patients with metastatic breast cancer. Although there was a significant survival advantage 
observed with eribulin compared to capecitabine in all subgroups, median OS was 14.4 months in 
the TNBC subgroup, highlighting the need for further efforts to improve clinical outcomes in these 

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patients(15). Increased PFS has been documented with the anti-angiogenic agent bevacizumab 
(monoclonal antibody targeting vascular endothelial growth factor; VEGF) in combination with 
taxanes, anthracyclines or capecitabine, albeit without OS benefit(16, 17). Other targeted 
therapies, including anti-VEGF (sorafenib, sunitinib) and anti-EGFR (cetuximab) drugs, have 
achieved ORR of only 10-20%(18, 19).
Overall, standard chemotherapy regimens may be considered effective for a subgroup of patients 
with early chemosensitive TNBC. However, patients with advanced disease typically respond 
poorly to current chemotherapeutic strategies and, when response is achieved, patients generally 
present rapid disease progression. Due to the modest progress in advanced TNBC, new strategies 
are warranted in order to improve survival and identify biomarkers that may predict response to 
treatment. 
Role of Platinum Agents in Metastatic TNBC
Platinum agents have demonstrated activity in monotherapy, and in combination with other 
chemotherapy drugs, in patients with anthracycline-pretreated advanced breast cancer(20). Several 
phase II studies have evaluated the combination of carboplatin and paclitaxel in metastatic breast 
cancer with response rates reported from 43% to 62% (21-23). This regimen has also been found 
to be effective in phase III trials with response rates between 38% and 41% and manageable 
toxicity(24, 25). Other platinum-based combinations are also active in patients with metastatic 
TNBC(26), with response rates of approximately 32% observed in combination with 
gemcitabine(27, 28).
BRCA1/2 mutation-associated and some sporadic TNBC share impaired homologous 
recombination repair mechanisms (HR-deficiency), conferring sensitivity to platinums(29). The 
Translational Breast Cancer Research Consortium (TBCRC) conducted a single-arm phase II study 
(TBCRC009) of cisplatin (75 mg/m2) or carboplatin (AUC 6) every three weeks in patients with 
first- or second-line metastatic TNBC. A total of 86 patients were enrolled in the trial, and prior 
adjuvant chemotherapy had been administered in 86% of the population. An overall response rate 
of 25.6% was observed, 29.0% in first-line and 11.8% in second-line setting. Response with 
cisplatin was 32.6% compared to 18.6% with carboplatin, although this was not statistically 
different (p=0.22). At a median follow-up of 49.9 months, median PFS was 2.9 months and OS 
was 11 months. Germline BRCA1/2 status was available in 77 patients. A total of 11 (14%) patients 
had germline BRCA1/2 mutation and 66 (86%) were BRCA1/2 wild type. The response rate was 
54.5% in BRCA mutation carriers vs. 19.7% in non-carriers (p=0.02), although no differences in 
PFS or OS were noted between both groups. Single agent platinum was well-tolerated and active 
in this setting(30).
The TNT trial evaluated single agent carboplatin (AUC 6) or docetaxel 100 mg/m2, administered 
every 3 weeks for 6 cycles, in patients with advanced TNBC who had received no prior treatment 
or only anthracycline-based chemotherapy for metastatic disease(31). Similar efficacy was 
demonstrated with single agent carboplatin and docetaxel for patients with TNBC. The objective 
response rate was 31.4% for the patients receiving carboplatin and 35.6% for the patients receiving 
docetaxel. Median PFS and OS were 3.1 and 12.4 months, respectively, in patients receiving 
carboplatin, and 4.5 and 12.3 months, respectively, in patients treated with docetaxel. Although no 

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significant improvement in PFS, OS or ORR was noted in the global population, patients with 
BRCA1 or BRCA2 mutations had a significant increase in objective response rates (58% vs. 33.3%) 
and PFS (6.8 months vs. 4.8 months, p) with carboplatin compared to docetaxel. Consequently, 
platinum agents are increasingly being used in early therapeutic lines for metastatic TNBC, with 
particular interest in patients with tumors characterized by HRD.
2.2
The PD-1/PD-L1 pathway in cancer
The importance of intact immune surveillance in controlling outgrowth of neoplastic 
transformation has been known for decades(32, 33). Accumulating evidence shows a correlation 
between tumor-infiltrating lymphocytes (TILs) in cancer tissue and favorable prognosis in various 
malignancies(34). In particular, the presence of CD8+ T-cells and the ratio of CD8+ effector T-
cells / FoxP3+ regulatory T-cells appear to correlate with improved prognosis and long-term 
survival in many solid tumors(35-37).
The PD-1 receptor-ligand interaction is a major pathway hijacked by tumors to suppress immune 
control(38). The normal function of PD-1, which is expressed on the cell surface of activated T 
cells under healthy conditions, is to down-modulate unwanted or excessive immune responses, 
including autoimmune reactions. PD-1 (encoded by the gene Pdcd1) is a member of the Ig 
superfamily related to CD28 and CTLA-4, which has been shown to negatively regulate antigen 
receptor signaling upon engagement of its ligands (PD-L1 and/or PD-L2). The structures of murine 
PD-1 alone(39) and in complex with its ligands were first resolved(40, 41). More recently the 
NMR-based structure of the human PD-1 extracellular region and analyses of its interactions with 
its ligands were also reported(42). PD-1 and family members are type I transmembrane 
glycoproteins containing an Ig Variable-type (V-type) domain responsible for ligand binding and 
a cytoplasmic tail which is responsible for the binding of signaling molecules.  The cytoplasmic 
tail of PD-1 contains 2 tyrosine-based signaling motifs, an immunoreceptor tyrosine-based 
inhibition motif (ITIM) and an immunoreceptor tyrosine-based switch motif (ITSM).  Following 
T-cell stimulation, PD-1 recruits the tyrosine phosphatases SHP-1 and SHP-2 to the ITSM motif 
within its cytoplasmic tail, leading to the dephosphorylation of effector molecules such as CD3ζ, 
PKCθ and ZAP70 which are involved in the CD3 T-cell signaling cascade(43). The mechanism 
by which PD-1 down modulates T-cell responses is similar to, but distinct from that of CTLA-
4(44), as both molecules regulate an overlapping set of signaling proteins.  PD-1 was shown to be 
expressed on activated lymphocytes including peripheral CD4+ and CD8+ T-cells, B-cells, T regs 
and Natural Killer cells(45). Expression has also been shown during thymic development on CD4-
CD8- (double negative) T-cells(46), as well as subsets of macrophages(47) and dendritic cells(48).  
The ligands for PD-1 (PD-L1 and PD-L2) are constitutively expressed or can be induced in a 
variety of cell types, including non-hematopoietic tissues as well as in various tumors(49). PD-L1 
is expressed at low levels on various non-hematopoietic tissues, most notably on vascular 
endothelium, whereas PD-L2 protein is only detectably expressed on antigen-presenting cells 
found in lymphoid tissue or chronic inflammatory environments(49). Binding of either PD-1 
ligand to PD-1 inhibits T-cell activation triggered through the T-cell receptor. PD-L2 is thought to 
control immune T-cell activation in lymphoid organs, whereas PD-L1 serves to dampen 
unwarranted T-cell function in peripheral tissues. Although healthy organs express little (if any) 
PD-L1, a variety of cancers were demonstrated to express abundant levels of this T-cell 

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inhibitor(50, 51), which, via its interaction with the PD-1 receptor on tumor-specific T cells, plays 
a critical role in immune evasion by tumors(52). This suggests that the PD-1/PD-L1 pathway 
should be considered an attractive target for therapeutic intervention in cancer(53).
The PD-1/PD-L1 pathway in breast cancer
Unlike melanoma and NSCLC, breast cancer has not been intensively investigated for its 
susceptibility to immunotherapy in clinical settings. However, there are accumulating preclinical 
and clinical evidence suggesting that the immune system is critical during natural history of breast 
cancer and that the immune system can be modulated to improve outcomes in this disease(54). It 
has been recognized that breast cancer is capable of stimulating the immune system and many 
breast tumors have substantial lymphocyte infiltration(55, 56). Additionally, this pathologic 
feature has prognostic implications, as lymphocyte predominant breast cancers are associated with 
improved prognosis(55, 57). However, the degree of immune infiltration differs by breast cancer 
subtype; while a substantial proportion of TNBC are richly infiltrated, hormone-receptor positive 
breast cancer is poorly T-cell infiltrated(58). Recently, it has been demonstrated that the expression 
of PD-1 and PD-L1 differs among breast tumors subtype: HR-positive (30% PD-1; 33% PD-L1), 
triple-negative (70% PD-1; 59% PD-L1) and HER2-positive (60% PD-1; 20% PD-L1)(59).
Results from several clinical trials evaluating PD-1 or PD-L1 checkpoint inhibitors in the TNBC 
metastatic setting have been reported (Table 1)(60-63). However, comparisons are limited due to 
broad variations in the inclusion criteria of each study, including prior number of therapies 
allowed, pre-selection based on PD-L1 positivity and assays used to quantify PD-L1 expression.
Table 1. Results of PD-1/PD-L1 Blockade in Advanced Triple-Negative Breast Cancer in 
2017
Pembrolizumab in 
PD-L1+ Tumors: 
TNBC Cohort 
(KEYNOTE-012)
Atezolizumab in 
Tumors Unselected 
for PD-L1: 
TNBC Cohort
Atezolizumab + Nab-
Paclitaxel in Tumors 
Unselected for PD-
L1: TNBC Cohort
Avelumab in Breast 
Cancer Unselected 
for PD-L1: TNBC 
Cohort (JAVELIN)
Mechanism of action
Humanized IgG4 
Anti-PD-1
Humanized IgG1 
Anti-PD-L1
Humanized IgG1 
Anti-PD-L1
Fully human IgG1 
Anti-PD-L1
Dose and Schedule
10 mg/kg (Q2W)
15mg/kg or 20 mg/kg 
or 1200mg flat dose 
(Q3W)
Atezolizumab 800mg 
(D1,15); nab-Paclitaxel 
125mg/kg (D 1,8,15) 
Q4W
10 mg/kg (Q2W)
PD-L1 positivity definition
≥1% TC or any 
staining in stroma
≥5% IC
≥1% IC;                            
≥1% TC
≥1% TC;                        
≥10% IC
PD-L1 clone assay
22C3 (Dako)
22C3 (Dako)
SP142 (Ventana)
NA (Dako-based test)
PD-L1 status inclusion 
criteria
Positive
All-comers †
All-comers
All-comers
No. PD-L1+ pts / No. 
PD-L1 evaluable cases, %
65/111 (58.6)
37/54 (68.5)
9/24 (37.5);                      
3/24 (12.5)
33/48 (68.8);                 
9/48 (18.8)
No. pts enrolled
32
54
32
58
No. pts included in 
efficacy analysis
27
21 †
24
58
No. prior therapies for 
metastatic disease, Median 
(range)
2 (0-9)
NA
5 (1-10)
NA

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No. pts with ≥3 prior 
therapies for metastatic 
disease (%)
15 (46.9)
NA ‡
1 (4.2)
13 (22.4)
ORR, %
18.5
19.0
37.5
8.6
ORR in PD-L1+ cohort, %
18.5
19.0
36.3 ¶
6.1;                                
44.4
CBR, %
25.9
NA
81.3
31.0
Median PFS, mo
1.9 (1.7-5.5)
NA
NA
NA
PFS rate at 6 mo, %
24.4
27
NA
NA
Median OS, mo
11.2 (5.3-NR)
NA
NA
NA
TNBC: triple-negative breast cancer; no: number; pts: patients; TC: tumor cells; IC: immune cells; ORR: overall 
response rate; CBR: clinical benefit rate (defined as complete response, partial response or stable disease for ≥24 wks); 
wks: weeks; months; NR: not reached; NA: not available; PFS: progression-free survival; OS: overall survival.
† All evaluable patients were PD-L1 positive. Data for PD-L1 negative tumors: NA.
‡ No. Pts with ≥4 lines of prior therapy for advanced disease: 48 (88.9%).
¶ According to PD-L1 positivity in IC.
2.3
Rationale for Crossover Amendment and Clinical Trial Implications
2.3.1
Rationale for Crossover Arm to Nab-Paclitaxel plus Nivolumab
More recently, results from a large phase III randomized trial (IMpassion130) comparing nab-
paclitaxel plus atezolizumab versus nab-paclitaxel alone as first-line therapy for advanced TNBC 
demonstrated a significant, though modest, clinical improvement in median PFS in the intent-to-
treat (ITT) population (7.2 vs. 5.5 months, HR 0.80, p=0.0025) and PD-L1-positive study 
population (7.5 vs. 5.0 months, HR 0.62, p<0.001)(64). PD-L1 positivity was defined as PD-L1 
staining on at least 1% of tumor-infiltrating immune cells as determined using the SP142 
monoclonal antibody (Ventana Medical Systems).
A hierarchical statistical plan allowed analysis of OS in the PD-L1 population if a significant 
difference was noted in the ITT population. In the ITT population, median OS was not significantly 
different between treatment arms (21.3 vs. 17.6 months, HR 0.84, p=0.08). Thus, formal testing of 
OS in the PD-L1-positive population was not performed at the time of the interim analysis. 
However, OS in the PD-L1-positive population was explored; at a median follow up of 12.9 
months, a significant 9.5-month increase in median OS was observed in patients treated with the 
combination versus chemotherapy alone (25.0 vs. 15.5 months, HR 0.62, 95% CI 0.45-0.86). This 
OS improvement led to the U.S. FDA accelerated approval of atezolizumab in combination with 
nab-paclitaxel for patients with locally advanced or metastatic TNBC whose tumors express PD-
L1 (PD-L1 tumor-infiltrating immune cells of any intensity covering at least 1% of the tumor area), 
as 
determined 
by 
an 
FDA 
approved 
test 
(https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/ucm633065.htm).
In the first version of this protocol, patients randomized to receive carboplatin alone (Arm B) were 
offered the possibility of crossover to single-agent nivolumab at the time of progression on 
carboplatin. Considering the approval of the combination of a taxane with PD-L1 inhibition, and 
given the modest efficacy of PD-1/PD-L1 inhibitors as single-agents in metastatic TNBC, the 
Crossover phase has been changed from nivolumab alone to nab-paclitaxel plus nivolumab. This 
will allow all patients enrolled on the study to receive immune checkpoint inhibition plus 

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chemotherapy either as first- or second-line therapy for metastatic TNBC. Please note: At the time 
of the crossover amendment activation (protocol version 3), any active patients on the original 
crossover treatment (nivolumab monotherapy) will continue to receive nivolumab monotherapy 
rather than nivolumab + nab-paclitaxel.
2.3.2
Rationale for Modifications to First Course of Therapy
It remains unclear whether the synergistic effect observed with PD-1/PD-L1 inhibition depends on 
the type of cytotoxic agent that is combined with the immune checkpoint inhibitor. Considering 
preclinical data with platinum (see Section 2.6.1), we aim to identify whether there is benefit in 
both unselected and PD-L1-positive TNBC patients. In addition, taxanes remain a standard part of 
neo-/adjuvant therapy in TNBC and, for patients whose tumors progress rapidly in the neo-
/adjuvant setting to paclitaxel, other chemotherapy options are needed. Thus, this study continues 
to address a clinically relevant question. Considering the characteristics of the study population 
included in IMpassion130, modifications to the following criteria will be made.
2.3.2.1
First-line metastatic setting only
Patients with previously untreated locally advanced or metastatic TNBC were allowed in 
IMpassion130(64). Thus, to compare carboplatin with or without nivolumab in metastatic 
TNBC, we will restrict eligibility to first-line patients only. Patients who have received 
prior platinum in the neo-/adjuvant setting will be eligible if at least 6 months have elapsed 
since the end of systemic therapy to the development of metastatic disease.
2.3.2.2
PD-L1 status as a stratification factor
Considering the current approval of PD-L1 inhibition plus nab-paclitaxel in patients with 
metastatic TNBC and positive PD-L1 status (as determined by the Ventana assay with 
SP142), known PD-L1 status will be required and included as a stratification factor in order 
to avoid selection bias toward PD-L1-negative TNBC. PD-L1-negative status will be 
restricted to 60% of the study population.
2.4
Nivolumab 
2.4.1
Mechanism of Action of Nivolumab
Nivolumab is a fully human, IgG4 (kappa) isotype monoclonal antibody that binds to PD-1 with 
nanomolar affinity (KD = 3.06 nM) and a high degree of specificity, thus precluding binding to its 
ligands PD-L1 and PD-L2. Nivolumab does not bind other related family members, such as BTLA, 
CTLA-4, ICOS or CD28. Pre-clinical testing of nivolumab demonstrated that blockade of PD-1 
results in enhanced T cell proliferation and expression of interferon-gamma (IFN-). In syngeneic 
mouse tumor models, blocking PD-1 activity resulted in decreased tumor growth.
2.4.2
Nonclinical Toxicology of Nivolumab
Carcinogenesis, Mutagenesis, Impairment of Fertility 

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Toxicology studies in cynomolgus monkeys revealed that nivolumab was well tolerated at doses 
up to 50 mg/kg given twice weekly for 27 doses. Drug related findings were limited to a reversible 
decrease in triiodothyronine (T3) by 28%, without concomitant abnormalities in other markers of 
thyroid function. No studies have been performed to assess the potential of nivolumab for 
carcinogenicity or genotoxicity. Preliminary new non-clinical safety findings of adverse 
pregnancy outcomes and infant losses in the absence of overt maternal toxicity have been reported. 
The findings of increased late stage pregnancy loss and early infant deaths/euthanasia in nivolumab 
exposed pregnant monkeys suggest a potential risk to human pregnancy if there is continued 
treatment with nivolumab during pregnancy.
Animal Toxicology and/or Pharmacology 
In animal models, inhibition of PD-1 signaling increased the severity of some infections and 
enhanced inflammatory responses. M. tuberculosis–infected PD-1 knockout mice exhibit 
markedly decreased survival compared with wild-type controls, which correlated with increased 
bacterial proliferation and inflammatory responses in these animals. PD-1 knockout mice have 
also shown decreased survival following infection with lymphocytic choriomeningitis virus.
2.4.3
Pharmacodynamics of Nivolumab
Based on dose/exposure efficacy and safety relationships, there are no clinically significant 
differences in safety and efficacy between a nivolumab dose of 240 mg or 3 mg/kg every 2 
weeks in patients with melanoma, NSCLC, RCC, and urothelial carcinoma. The FDA approved 
dose of nivolumab in these three settings is a flat dose of 240 mg every 2 weeks.
2.4.4
Pharmacokinetics of Nivolumab
Pharmacokinetics (PK) of nivolumab was studied in patients over a dose range of 0.1 to 20 
mg/kg administered as a single dose or as multiple doses every 2 or 3 weeks. Nivolumab 
clearance decreases over time, with a mean maximal reduction (% coefficient of variation 
[CV%]) from baseline values of approximately 24.5% (47.6%) resulting in a geometric mean 
steady state clearance (CLss) (CV%) of 8.2 mL/h (53.9%); the decrease in CLss is not 
considered clinically relevant. The geometric mean volume of distribution at steady state (Vss) 
(CV%) is 6.8 L (27.3%), and geometric mean elimination half-life (t1/2) is 25 days (77.5%). 
Steady-state concentrations of nivolumab were reached by approximately 12 weeks when 
administered at 3 mg/kg every 2 weeks, and systemic accumulation was approximately 3.7-fold. 
The exposure to nivolumab increased dose proportionally over the dose range of 0.1 to 10 mg/kg 
administered every 2 weeks.
Specific Populations: The population PK analysis suggested that the following factors had no 
clinically important effect on the clearance of nivolumab: age (29 to 87 years), weight (35 to 160 
kg), gender, race, baseline LDH, PD-L1 expression, solid tumor type, tumor size, renal 
impairment, and mild hepatic impairment.
Renal Impairment: The effect of renal impairment on the clearance of nivolumab was evaluated 
by a population PK analysis in patients with mild (eGFR 60 to 89 mL/min/1.73 m2; n=313), 
moderate (eGFR 30 to 59 mL/min/1.73 m2; n=140), or severe (eGFR 15 to 29 mL/min/1.73 m2; 

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n=3) renal impairment. No clinically important differences in the clearance of nivolumab were 
found between patients with renal impairment and patients with normal renal function.
Hepatic Impairment: The effect of hepatic impairment on the clearance of nivolumab was 
evaluated by population PK analyses in patients with mild hepatic impairment (total bilirubin 
[TB] less than or equal to the upper limit of normal [ULN] and AST greater than ULN or TB less 
than 1 to 1.5 times ULN and any AST; n=92). No clinically important differences in the 
clearance of nivolumab were found between patients with mild hepatic impairment and patients 
with normal hepatic function. Nivolumab has not been studied in patients with moderate (TB 
greater than 1.5 to 3 times ULN and any AST) or severe hepatic impairment (TB greater than 3 
times ULN and any AST)(65).
2.4.5
Clinical Experience with Nivolumab 
2.4.5.1
Safety of Nivolumab in Clinical Trials 
The overall safety experience with nivolumab, as monotherapy or in combination with other 
therapeutics, is based on experience in over 6,000 subjects treated to date with nivolumab 
monotherapy in single-or multiple-dose Phase 1/2/3 studies, or studies with nivolumab in 
combination with other therapeutics. The AE profile has been consistent across multiple tumor 
types, with no maximum tolerated dose reached at any monotherapy dose tested up to 10 mg/kg. 
Treatment-related AEs have included pulmonary toxicity, renal toxicity (including acute renal 
failure), endocrine abnormalities, GI toxicity, dermatologic toxicity (including rash), and 
hepatotoxicity. In most cases, these AEs have been managed successfully with supportive care 
and, in more severe cases, a combination of dose delay, permanent discontinuation, and/or 
initiation of systemic corticosteroids. Preliminary safety and tolerability data remain consistent 
with the profile of nivolumab in monotherapy across tumor types, with the exception of 
pneumonitis which may be numerically greater in subjects with NSCLC, possibly due to difficulty 
in distinguishing between treatment-related and disease-related pulmonary symptoms or 
radiographic changes(66). In several ongoing clinical trials, the safety of nivolumab in 
combination with other therapeutics such as ipilimumab, cytotoxic chemotherapy, anti-
angiogenics and targeted therapies is being explored. Most studies are ongoing and as such, the 
safety profile of nivolumab combinations continues to evolve. The most advanced combination 
under development is nivolumab and ipilimumab in subjects with melanoma. Thus far, the 
combination of both agents has revealed overall a manageable toxicity profile.
Overall, the safety profile of nivolumab monotherapy as well as combination therapy is 
manageable and generally consistent across completed and ongoing clinical trials with no MTD 
reached at any dose tested, up to 10 mg/kg. There was no pattern in the incidence, severity, or 
causality of adverse events (AEs) according to nivolumab dose level. Most AEs were low grade 
(grade 1 to grade 2) with relatively few related high grade (grade 3 to grade 4) AEs. Most high 
grade events were manageable with the use of corticosteroids or hormone replacement therapy for 
endocrinopathies. Management algorithms including the use of immunosuppressive agents, such 
as corticosteroids, infliximab, etc., are provided in Section 6 of this protocol. Nivolumab should 
not be used in subjects with active autoimmune disease given the mechanism of action of the 
antibody.

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Updated overall safety data for nivolumab is available in the current version of the Investigator’s 
Brochure. The Investigator’s Brochure should be reviewed in conjunction with this study protocol.
2.4.5.2
Efficacy of Nivolumab in Clinical Trials
Nivolumab has demonstrated clinical activity, leading to U.S. Food and Drug Administration 
approval as a single agent or in combination, in a variety of solid tumor malignancies:
1) Unresectable or metastatic melanoma, regardless of BRAF mutational status: as a 
single-agent at a dose of 240 mg intravenously every 2 weeks or 480 mg every 4 weeks, 
or in combination with ipilimumab (nivolumab at 1mg/kg every 3 weeks for 4 doses, 
followed by nivolumab 240 mg every 2 weeks or 480 mg every 4 weeks).
2) Melanoma with lymph node involvement or metastatic disease after complete 
resection, in the adjuvant setting as single-agent at a dose of 240 mg intravenously 
every 2 weeks or 480 mg every 4 weeks.
3) Metastatic non-small cell lung cancer (NSCLC) with progression on or after platinum-
based chemotherapy, at a dose of 240 mg intravenously every 2 weeks or 480 mg every 
4 weeks. Patients with EGFR or ALK genomic tumor aberrations should have disease 
progression on FDA-approved therapy for these aberrations prior to receiving 
nivolumab. 
4) Metastatic small cell lung cancer (SCLC) after platinum-based chemotherapy and at 
least one other line of therapy, at a dose of 240 mg intravenously every 2 weeks.
5) Advanced renal cell carcinoma after progression of anti-angiogenic therapy, at a dose 
of 240 mg intravenously every 2 weeks or 480 mg every 4 weeks.
6) Untreated advanced renal cell carcinoma in patients with intermediate or poor risk, in 
combination with ipilimumab (nivolumab at 1mg/kg every 3 weeks for 4 doses, 
followed by nivolumab 240 mg every 2 weeks or 480 mg every 4 weeks).
Classical Hodgkin lymphoma that has relapsed or progressed after autologous 
hematopoietic stem cell transplantation (HSCT) and post-transplantation brentuximab 
vedotin, or 3 or more lines of systemic therapy that includes HSCT, at a dose of 240 
mg intravenously every 2 weeks or 480 mg every 4 weeks .
7) Recurrent or metastatic squamous cell carcinoma of the head and neck with progression 
on or after platinum-based therapy, at a dose of 240 mg intravenously every 2 weeks 
or 480 mg every 4 weeks.
8) Locally advanced or metastatic urothelial carcinoma after progression on platinum-
based chemotherapy or within 12 months of neo-/adjuvant treatment with platinum-
based chemotherapy, based on tumor response rate and duration of response, at a dose 
of 240 mg intravenously every 2 weeks or 480 mg every 4 weeks.
9) Adult and pediatric (12 years and older) patients with microsatellite instability-high 
(MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer that has 
progressed following treatment with a fluoropyrimidine, oxaliplatin and irinotecan, as 
a single-agent (240 mg intravenously every 2 weeks) or in combination with 
ipilimumab (nivolumab at 1mg/kg every 3 weeks for 4 doses, followed by nivolumab 
240 mg every 2 weeks).
10) Hepatocellular carcinoma previously treated with sorafenib, at a dose of 240 mg every 
2 weeks or 480 mg every 4 weeks.

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Updated overall clinical experience for nivolumab is available in the current version of the 
Investigator’s Brochure. The Investigator’s Brochure should be reviewed in conjunction with this 
study protocol.
2.4.6
Ongoing Trials of Nivolumab in Breast Cancer
Nivolumab is currently being explored in many tumor types and in combination with various 
treatments, such as chemotherapy, radiotherapy, small molecule inhibitors (i.e tyrosine kinase 
inhibitors) and other immune checkpoint inhibitors. Safety and efficacy results of nivolumab 
alone or in combination with ipilimumab (anti-CTLA4) in breast cancer patients have not yet 
been published. A phase 1/2, open-label study of nivolumab in monotherapy (at a dose of 
3mg/kg intravenously every 2 weeks) or nivolumab combined with ipilimumab (nivolumab at 1 
mg/kg intravenously plus ipilimumab 3 mg/kg every 3 weeks for 4 doses followed by nivolumab 
3 mg/kg every 2 weeks) in subjects with advanced or metastatic solid tumors (NCT01928394) 
recently closed to accrual; results from patients enrolled on the TNBC cohort are pending.
In recurrent HER2-negative metastatic breast cancer, a phase 1 study (NCT02309177) has been 
completed to determine the safety of the combination of nivolumab and nab-paclitaxel at two 
dose regimens (nab-paclitaxel at 100mg/m2 on days 1, 8 and 15 of each 28-day cycle, plus 
nivolumab on days 1 and 15 starting in cycle 3; nab-paclitaxel at 260mg/m2 on days 1 of each 
21-day cycle, plus nivolumab on days 15 starting in cycle 3). In this trial, other dose regimens of 
this combination have been explored in additional cohorts for pancreatic and non-small cell lung 
cancer (NSCLC) (see section 2.6.5).
The TONIC trial (NCT02499367) is a phase II randomized non-comparative study evaluating the 
safety and efficacy of nivolumab at a dose of 3 mg/kg every 2 weeks after an induction treatment 
(radiation therapy on a metastatic lesion or doxorubicin 15 mg flat dose once weekly for 2 weeks 
or metronomic cyclophosphamide 50 mg daily orally for 2 weeks or cisplatin 40 mg/m2 weekly 
for 2 weeks, or no induction) in patients with metastatic TNBC. A ¨pick-the-winner¨ strategy was 
used in the first stage of the trial to discontinue early a cohort if the response rate (with n=10) was 
≤30%, and to identify the most promising cohort for expansion in stage II. In stage I, a total of 70 
patients were randomized to one of the 5 cohorts and 66 were evaluable for efficacy(67). Of note, 
46 (72%) of patients were considered PD-L1-positive, defined as ≥5% of staining on immune cells. 
The overall response rate (ORR) was highest in the doxorubicin (35%) and cisplatin (23%) cohorts, 
and lowest in the radiation (8%) and cyclophosphamide (8%) cohorts, with an ORR of 17% in the 
arm without induction. Of patients who achieved a complete or partial response, 85% were alive 
at one-year, compared to 21% of those who did not respond to treatment. Compared to baseline, 
tumors treated with cisplatin had upregulation of several immune signatures – particularly CD8 
and T-cell signatures after the 2-week induction phase, and CD8, cytotoxic cells, T-cells, PD-1, 
PD-L1, tumor-inflammation signature in biopsies after 8 weeks (while on nivolumab). In addition, 
in biopsies on nivolumab, more clonal T-cells were observed in responders (n=4) versus non-
responders (n=25) across cohorts. Increased T-cells and T-cell clonality were observed after 
exposure to cisplatin and doxorubicin, and while on nivolumab, in these two cohorts(67).

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2.5
Carboplatin
2.5.1
Mechanism of Action of Carboplatin 
Carboplatin, like cisplatin, produces predominantly intrastrand and interstrand DNA cross-
links(68). This effect is apparently cell-cycle nonspecific. The aquation of carboplatin, which is 
thought to produce the active species, occurs at a slower rate than in the case of cisplatin. Despite 
this difference, it appears that both carboplatin and cisplatin induce equal numbers of drug-DNA 
cross-links, causing equivalent lesions and biological effects. The differences in potencies for 
carboplatin and cisplatin appear to be directly related to the difference in aquation rates.
2.5.2
Nonclinical Toxicology of Carboplatin
Carcinogenesis, Mutagenesis, Impairment of Fertility 
The carcinogenic potential of carboplatin has not been studied, but compounds with similar 
mechanisms of action and mutagenicity profiles have been reported to be carcinogenic. 
Secondary malignancies have been reported in association with multi-drug therapy. Carboplatin 
has been shown to be mutagenic both in vitro and in vivo. It has also been shown to be 
embryotoxic and teratogenic in rats receiving the drug during organogenesis. 
2.5.3
Pharmacokinetics
In patients with creatinine clearances of about 60 mL/min or greater, plasma levels of intact 
carboplatin decay in a biphasic manner after a 30-minute intravenous infusion of 300 mg/m2 to 
500 mg/m2 of carboplatin. The initial plasma half-life (alpha) was found to be 1.1 to 2 hours 
(n=6), and the postdistribution plasma half-life (beta) was found to be 2.6 to 5.9 hours (n=6). The 
total body clearance, apparent volume of distribution and mean residence time for carboplatin are 
4.4 L/hour, 16 L and 3.5 hours, respectively. The Cmax values and areas under the plasma 
concentration versus time curves from 0 to infinity (AUC inf) increase linearly with dose, 
although the increase was slightly more than dose proportional. Carboplatin, therefore, exhibits 
linear pharmacokinetics over the dosing range studied (300 mg/m2 to 500 mg/m2). 
Carboplatin is not bound to plasma proteins. No significant quantities of protein-free, 
ultrafilterable platinum-containing species other than carboplatin are present in plasma. 
However, platinum from carboplatin becomes irreversibly bound to plasma proteins and is 
slowly eliminated with a minimum half-life of 5 days. 
The major route of elimination of carboplatin is renal excretion. Patients with creatinine 
clearances of approximately 60 mL/min or greater excrete 65% of the dose in the urine within 12 
hours and 71% of the dose within 24 hours. All of the platinum in the 24-hour urine is present as 
carboplatin. Only 3% to 5% of the administered platinum is excreted in the urine between 24 and 
96 hours. There are insufficient data to determine whether biliary excretion occurs. 
In patients with creatinine clearances below 60 mL/min, the total body and renal clearances of 
carboplatin decrease as the creatinine clearance decreases. carboplatin dosages should therefore 
be reduced in these patients. The primary determinant of carboplatin clearance is glomerular 

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filtration rate (GFR) and this parameter of renal function is often decreased in elderly patients. 
Dosing formulas incorporating estimates of GFR to provide predictable carboplatin plasma 
AUCs should be used in elderly patients to minimize the risk of toxicity. 
2.5.4
Clinical Experience with Carboplatin 
2.5.4.1
Safety of Carboplatin in Metastatic TNBC
In TBCRC009, 43 patients with metastatic TNBC were treated with carboplatin in the first- or 
second-line setting (Table 2)(30). Single-agent carboplatin had generally mild toxicity, with 
fatigue, nausea, electrolyte abnormalities and hematologic toxicity among the most common. 
Grade 3 and 4 adverse events were rare; those occurring in at least 5% of all patients included 
fatigue, neutropenia, dyspnea, anemia, hyperglycemia and hyponatremia. No treatment-related 
deaths were reported.
Table 2. Toxicity reported with carboplatin in TBCRC009
All Grade Toxicity in > 10% of Patients in the TBCRC 009 Trial
Carboplatin
(n=43)
No. of patients
%
Neutropenia
15
35
Lymphopenia
9
21
Anemia
28
65
Thrombocytopenia
20
47
Hematologic
Febrile neutropenia
4
9
Fatigue / Malaise
28
65
Decreased appetite
4
9
Peripheral neuropathy
15
35
Diarrhea
3
7
Constipation
11
26
Nausea
27
63
Gastrointestinal
Vomiting
10
23
Increased ALT
9
21
Hepatic
Increased AST
13
30
Pulmonary
Dyspnea
12
28
Metabolism / 
Electrolyte alterations
Hyperglycemia
19
44
Hypomagnesemia
10
23
Hyponatremia
6
14
Hypokalemia
5
12
Hypocalcemia
5
12
Hypoalbuminemia
5
12
Skin/Mucosa
Rash
5
12
Grade 3 and 4 Adverse Events in > 5% of Patients in the TBCRC 009 Trial
Carboplatin
(n=43)
No. of patients
%
Fatigue
2
5
Neutropenia
4
9

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Dyspnea
2
5
Anemia
4
9
Hyperglycemia
3
7
Hyponatremia
1
2
2.6
Combination of Carboplatin and Nivolumab
2.6.1
Rationale for the Combination of Carboplatin and Nivolumab
The discovery of the critical role that the overexpression of immune checkpoint molecules in the 
tumor microenvironment plays in antitumor immunity evasion and cancer progression has 
revolutionized cancer treatment(69). Anti-PD-1/PD-L1 antibodies have demonstrated clinical 
activity in more than 15 cancer types, and two PD-1 inhibitors (nivolumab and pembrolizumab) 
are FDA approved for the treatment of advanced melanoma, non-small-cell lung carcinoma and 
renal cell carcinoma(70-72). More than 1,000 clinical trials of checkpoint blockers are currently 
ongoing.
Although breast cancer has not been traditionally considered an immunogenic neoplasia, 
increasing preclinical and clinical data suggest that the interaction with the immune system is 
critical for disease outcome in this tumor type(54). It is now recognized that a fraction of breast 
tumors, especially TNBC, have substantial lymphocyte infiltration and that this pathologic feature 
has prognostic implications(56, 73). Neoadjuvant studies in TNBC have revealed that lymphocyte-
predominant breast cancer (LPBC) is associated with higher pathologic complete response rates 
(pCR)(74) and that the presence of TILs in residual disease correlates with improved overall 
survival(75). In GeparSixto, patients with LPBC triple-negative tumors obtained significantly 
greater pCR with the addition of carboplatin to paclitaxel and non-pegylated liposomal 
doxorubicin, whereas no significant differences were noted between neoadjuvant regimens in 
patients with non-LPBC (Figure 1)(56).
Figure 1. Pathologic complete response (pCR) rates in the triple-negative subgroup of patients treated with 
neoadjuvant chemotherapy in GeparSixto. LPBC = lymphocyte-predominant breast cancer; Cb = Carboplatin; P= 
Paclitaxel; M = Non-pegylated liposomal doxorubicin. (Denkert et al. J Clin Oncol 2015)

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The elevated rates of PD-L1 and PD-1 expression in TNBC(59) have led to the development of 
clinical trials to evaluate checkpoint inhibition 
in this population(76). Atezolizumab, a 
monoclonal antibody targeting PD-L1, was 
evaluated in patients with metastatic PD-L1-
positive TNBC and demonstrated and ORR of 
19% and 6-month PFS of 27%(61). Similar 
results were found among the TNBC cohort of 
the KEYNOTE-012 study, preselected for PD-
L1 positivity, treated with the anti-PD-1 
inhibitor pembrolizumab (ORR of 18% and 6-
month PFS of 24%)(62). Data from the 
JAVELIN trial have revealed modest activity 
of avelumab, a PD-L1 antibody, in patients 
with metastatic breast cancer unselected for 
PD-L1 expression, with an ORR of 8.6% in the TNBC subgroup(63).
These results demonstrate that, although some patients with TNBC may derive clinical benefit 
from checkpoint blockade, in most cases single-agent PD-1/PD-L1 inhibitors are insufficient to 
control disease burden. Immunosuppressive mechanisms within the tumor microenvironment may 
play a role in de novo resistance to these therapies. Some of these mechanisms have been identified, 
and now provide targets for combination therapy(77). Considerably higher response rates have 
been noted with atezolizumab and albumin-bound paclitaxel in metastatic TNBC, particularly in 
the first-line setting in which a confirmed ORR of 46% was observed(78). Activity of the 
combination of immunotherapy and chemotherapy in this trial was evident regardless of PD-L1 
positivity. This has encouraged further evaluation of immune checkpoint inhibitors in combination 
with chemotherapy in clinical trials, expecting to enhance the benefit of either strategy alone.
Furthermore, platinum agents are DNA-crosslinkers that cause the accumulation of genotoxic 
stress. Colleagues at Dana-Farber Cancer Institute (DFCI) have demonstrated that new 
neoantigens are generated in tumor tissue following cisplatin treatment (data not yet published).  
Genotoxic stress, in turn, stimulates immune activation via interferon-γ signaling. Accordingly, 
platinum chemotherapy has been shown to generate CD8-driven anti-tumor immune responses in 
vitro and in vivo murine models(79), making the combination with immunotherapy an attractive 
therapeutic strategy. Platinum chemotherapy also enhances T cell activation through 
downregulation of PD-L1 and PD-L2 on dendritic cells, increasing their T cell activation potential 
and sensitizing tumor cells to cytotoxic T cell-mediated attack(80). Preclinical work at DFCI has 
shown significant improvement in tumor burden control with the addition of a PD-1 antibody to 
platinum chemotherapy in the 4T1 mouse model of TNBC (Figure 2; 1A12 = anti-PD1 clone; iso 
= isotype antibody control). 
Breast cancers that develop in patients that carry a germline BRCA1 or BRCA2 mutation 
are prone to genotoxic stress and, therefore, particularly sensitive to platinum chemotherapy(30, 
81, 82). This may render them especially susceptible to treatment with platinum plus PD-1 
blockade.  The clinical efficacy of immune stimulation in genomically unstable tumors has been 

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proven in microsatellite instability-high colon cancer(83). Here, this randomized phase II study 
will evaluate the efficacy of combined therapy with carboplatin plus nivolumab in metastatic 
TNBC, with sub-analyses specifically focused on activity in the BRCA1/2-mutant subgroup. 
Carboplatin will be administered at area under the curve (AUC) 6 every 21 days, as is the clinical 
standard in metastatic breast cancer, mimicking the dose and schedule used in the phase III TNT 
and phase II TBCRC009 TNBC trials referenced previously. Nivolumab will be administered at a 
flat dose of 360 mg every 21 days, in order to maintain consistency between cycles.
2.6.2
Rationale for Dose of Nivolumab 
The U.S. FDA has approved nivolumab at a flat dose of 240 mg every 2 weeks, as a single 
agent, for NSCLC, melanoma and renal cell carcinoma. This was based on pharmacokinetic data 
data on file) that demonstrated that the 240 mg dose corresponded to the exposures observed 
with a dose of 3 mg/kg in an 80-kg patient, which was the approximate median body weight for 
patients in the nivolumab clinical trials. The range of predicted exposure with 240 mg overlapped 
with the range observed with 3 mg/kg across subjects with a wide range of body weights. Model-
based simulation results indicated that systemic exposure of nivolumab was similar between 3 
mg/kg or 240 mg flat dose, with a median percent difference in exposures of approximately 5%. 
Based on dose/exposure efficacy and safety relationships, there are no clinically significant 
differences in safety and efficacy between a nivolumab dose of 240 mg and 3 mg/kg every 2 weeks 
in patients with unresetable or metastatic melanoma, previously treated metastatic NSCLC and 
advanced renal cell carcinoma who have received prior antiangiogenic therapy.
Nivolumab demonstrated safety and linear pharmacokinetics with a dose range of 0.1mg/kg to 
10mg/kg across solid tumor types in the phase 1 study CA209-003(71). No relationship was noted 
between nivolumab exposure and risk of adverse events leading to discontinuation of therapy or 
death. The subgroup safety analysis did not demonstrate a relationship between body weight and 
frequency or severity of adverse events. To select the appropriate flat dose of nivolumab, a body 
weight distribution assessment was conducted using observed baseline body weights from 
melanoma, NSCLC and renal cell carcinoma across nivolumab clinical trials (solid tumor study: 
CA209-003; NSCLC studies: CA209-017, CA209-063, CA209-057; melanoma studies: CA209-
037, CA209-066, CA209-067; renal cell carcinoma: CA209-010, CA209-025). The approximate 
median body weight of these subjects was 80 kg (body weight range 35-160 kg in melanoma and 
NSCLC patients; 40-168 kg in renal cell carcinoma). Utilizing a dose of 3mg/kg, the corresponding 
flat dose was calculated to be 240mg. 
A model-based simulation was conducted to evaluate the predicted exposure of nivolumab 
administered 240 mg every 2 weeks. These simulation results were then compared to exposures in 
patients treated with nivolumab 3mg/kg every 2 weeks in the nine previously mentioned trials 
across melanoma, NSCLC and renal cell carcinoma. The percent difference in geometric mean of 
all measures after weight-based dosing and flat-dosing was approximately 5%. Flat dosing resulted 
in higher nivolumab exposure in lighter patients and lower exposures in higher body weight 
patients compared to body-weight dosing. However, the median and 95th percentile of nivolumab 
exposures across the weight range were below exposures observed with nivolumab 10mg/kg every 
2 weeks that was considered safe and tolerable. 

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Exposure-response analyses for both, efficacy and safety, were also conducted. The hazard ratios 
(HRs) for risk of death were estimated for nivolumab exposure following body-weight adjusted 
and flat dosing, and the HRs were similar between 3 mg/kg and 240 mg every 2 weeks across the 
three tumor types. The 95% confidence intervals (CI) of HRs for risk of death crossed 1.0, 
suggesting that a flat exposure-response relationship exists for nivolumab. Based on dose/exposure 
efficacy relationships, there are no clinically significant differences in efficacy between a 
nivolumab dose of 240 mg and 3 mg/kg every 2 weeks for these patients. In addition, no 
relationship was noted between nivolumab exposure and risk of adverse events leading to 
discontinuation of therapy or death. The HR was similar between nivolumab 3 mg/kg and 240 mg 
every 2 weeks. Based on dose/exposure efficacy relationships, there are no clinically significant 
differences in safety between a nivolumab dose of 240 mg and 3 mg/kg every 2 weeks for these 
patients (
 data on file).
Nivolumab has been explored in an every 3-week schedule in a phase 1 study (CheckMate 012) in 
combination with platinum-based doublet chemotherapy (PT-DC) in first-line advanced 
NSCLC(84). Patients (n=56) received nivolumab (intravenously) plus PT-DC concurrently every 
3 weeks for four cycles followed by nivolumab alone until progression or unacceptable toxicity. 
Regimens were nivolumab 10 mg/kg plus gemcitabine-cisplatin (squamous) or pemetrexed-
cisplatin (nonsquamous) or nivolumab 5 or 10 mg/kg plus paclitaxel 200mg/m2 – carboplatin AUC 
6 (all histologies) every 3 weeks. The study used a dose de-escalation design on the basis of the 
modified toxicity probability interval method, guided by the number of dose-limiting toxicities 
(DLTs) observed during the first two cycles (6 weeks) of therapy. Initially, six patients per arm 
were treated with nivolumab 10 mg/kg. Whereas the nivolumab 10 mg/kg dose was based on 
results from the phase 1 study CA209-003, the 5 mg/kg dose was added after a protocol 
amendment to assess the safety of a lower nivolumab dose in combination with paclitaxel-
carboplatin (which can be used for all histologic subtypes). Addition of this arm was not driven by 
safety, because no DLTs were observed with nivolumab 10 mg/kg, but rather, it was added on the 
basis of pharmacokinetic modeling showing that nivolumab 5 mg/kg every 3 weeks provides a 
steady-state trough concentration equivalent to nivolumab 3 mg/kg every 2 weeks(85).
Median OS was longer than expected for PT-DC alone (8.1 to 10.3 months), ranging from 11.6 to 
19.2 months across the nivolumab 10 mg/kg plus PT-DC arms. OS for the nivolumab 5 mg/kg plus 
paclitaxel-carboplatin arm was particularly notable; median OS was not reached (range, 8.8 to 
30.1+ months), and 57% of patients (eight of 14 patients) were still alive after a median follow-up 
time of more than 2 years. Although sample sizes were small, 1-year OS rates (50% to 87%) 
seemed similar to that reported with nivolumab monotherapy (73%) in CheckMate 012. It is 
unclear whether nivolumab plus PT-DC offers improved long-term OS benefit compared with 
nivolumab monotherapy. However, survival data with nivolumab 5 mg/kg every 3 weeks in 
combination with chemotherapy are encouraging(84) and are being further explored in a phase III 
trial (NCT02477826).
Another phase I trial conducted in Japan demonstrated that nivolumab at 10 mg/kg every 3 weeks 
was a safe and tolerable regimen in combination with carboplatin (AUC 6), paclitaxel (200 mg/m2) 
and bevacizumab (15 mg/kg), with the lowest rate of discontinuation of therapy due to adverse 
events (0 of 6 patients) compared to the other arms of nivolumab plus cisplatin- or docetaxel-based 
chemotherapy(86). In addition, in this study serum concentrations of nivolumab on cycle 1 day 22 

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were similar to those reported in monotherapy, suggesting that cytoxic chemotherapy does not 
influence serum concentration of nivolumab when the agents are given in combination.
In addition, clinical safety of flat dosing at 480 mg every 4 weeks has been compared to 3mg/kg 
Q2W(87). Across four phase 3 clinical trials in which patients with multiple tumor types who were 
treated with nivolumab 3mg/kg Q3W transitioned to flat dosing of 480 mg Q4W, time-averaged 
steady-state exposure and safety profile of nivolumab 480 mg Q4W were consistent with that of 
3mg/kg Q3W. Treatment-related adverse events that started after transitioning to the flat dose 
Q4W schedule were reported in 14.8% of patients (grade 3-4 toxicity in 1.6% of patients). No new 
safety signals were observed in this analysis.
Considering the linear pharmacokinetics of nivolumab at doses ranging from 0.1 to 10 mg/kg 
(every 2 weeks), in addition to data suggesting that this is not influenced by cytotoxic 
chemotherapy, a 3-week schedule estimated to correspond to a flat dose of 360 mg will be 
administered in the First Course of study treatment. For eligible patients randomized to Arm B 
(carboplatin alone) who elect to crossover to nab-Paclitaxel plus nivolumab after progression on 
carboplatin, a 4-week schedule estimated to correspond to a flat dose of 480 mg will be 
administered in the Crossover Phase.
2.6.3
Rationale for Shorter Infusion Time for Nivolumab
Long infusion times place a burden on patients and treatment centers. Establishing that nivolumab 
and ipilimumab can be safely administered using shorter infusion times of 30 minutes ’ duration 
will diminish the burden, provided that there is no change in the safety profile. Previous clinical 
studies of nivolumab and ipilimumab monotherapies and the combination of nivolumab and 
ipilimumab have used a 60‑minute infusion duration for nivolumab and a 90‑minute infusion 
duration for ipilimumab (1 - 3 mg/kg dosing for both). However, both nivolumab and ipilimumab 
have been administered at up to 10 mg/kg with the same infusion duration (ie, 60 minutes).
Nivolumab has been administered safely over 60 minutes at doses ranging up to 10 mg/kg over a 
long treatment duration. In subjects with advanced/metastatic clear cell RCC, a dose association 
was observed for infusion site reactions and hypersensitivity reactions (1.7% at 0.3 mg/kg, 3.7% 
at 2 mg/kg and 18.5% at 10 mg/kg). All the events were Grade 1/2 and were manageable. An 
infusion duration of 30 minutes for 3 mg/kg nivolumab (30% of the dose provided at 10 mg/kg) is 
not expected to present any safety concerns compared to the prior experience at 10 mg/kg 
nivolumab dose infused over a 60-minute duration.
Similarly, ipilimumab at 10 mg/kg has been safely administered over 90 minutes. In subjects with 
advanced Stage II or Stage IV melanoma, where ipilimumab was administered up to a dose of 10 
mg/kg, on-study drug related hypersensitivity events (Grade 1/2) were reported in 1 subject (1.4%) 
in the 0.3 mg/kg and in 2 subjects (2.8%) in the 10 mg/kg group. There were no drug-related 
hypersensitivity events reported in the 3 mg/kg group. Across the 3 treatment groups, no Grade 
3/4 drug-related hypersensitivity events were reported and there were no reports of infusion 
reactions. Ipilimumab 10 mg/kg monotherapy has also been safely administered as a 90-minute 
infusion in a large Phase 3 study in prostate cancer and as adjuvant therapy for Stage III melanoma, 
with infusion reactions occurring in subjects. Administering 3 mg/kg of ipilimumab represents 

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approximately one-third of the 10 mg/kg dose.
Overall, infusion reactions including high-grade hypersensitivity reactions have been uncommon 
across clinical studies of nivolumab. Furthermore, a 30-minute break after the first infusion for the 
combination cohort will ensure the appropriate safety monitoring before the start of the second 
infusion. Overall, a change in safety profile is not anticipated with 30-minute infusions of 
nivolumab.
2.6.4
Safety of the Combination of Carboplatin and Nivolumab
The safety of the combination of nivolumab and carboplatin has only been reported with doublet 
platinum-based regimens that include paclitaxel (Table 3). In CheckMate 012, the most common 
toxicities reported for the combination were those anticipated with PT-DC alone(84). The observed 
frequencies of treatment-related grade 3 or 4 nonhematologic toxicities, such as fatigue and nausea 
(0% to 13% and 0% to 7%, respectively), were consistent with those previously reported for 
paclitaxel-carboplatin (8% and 0% to 9%, respectively). The observed frequencies of immune-
related adverse events affecting the skin, GI, renal, and pulmonary organs were greater than 
expected with single-agent nivolumab (combination therapy vs. monotherapy: 36% vs. 25%, 23% 
vs. 12%, 14% vs. 0%, and 13% vs. 6%, respectively). However, these treatment-related AEs, 
including pneumonitis, were effectively managed with corticosteroids or infliximab and did not 
lead to any deaths. No treatment-related adverse events led to discontinuation of treatment during 
concurrent nivolumab and PT-DC therapy in the carboplatin-containing arms.
In the Japanese phase I study, no DLTs were observed in the nivolumab-carboplatin-paclitaxel-
bevacizumab arm(86). Hematological grade 3 or higher adverse events were present in all 6 
patients in this arm, although no non-hematological adverse events of grade 3 or worse were 
reported. There were no treatment-related deaths and there were no adverse events leading to 
discontinuation of nivolumab in the carboplatin arm. In 2 (33.3%) patients, chemotherapy was 
discontinued due to adverse events – epistaxis and peripheral neuropathy.
Table 3. Treatment-Related Adverse Events with Nivolumab in Combination with 
Carboplatin-Based Regimens in NSCLC
Carboplatin / Paclitaxel / 
Nivolumab 10mg/kg 
Q3W (n=15)*
Carboplatin / Paclitaxel / 
Nivolumab 5mg/kg Q3W 
(n=14)*
Carboplatin/ Paclitaxel / 
Bevacizumab / 
Nivolumab 10mg/kg 
Q3W (n=6) **
Any Grade
Grade 3-4
Any Grade
Grade 3-4
Any Grade
Grade 3-4
All adverse events
15 (100)
11 (73)
14 (100)
4 (29)
6 (100)
6 (100)
Neutropenia
2 (13)
1 (7)
0 (0)
0 (0)
6 (100)
6 (100)
Lymphopenia
3 (20)
0 (0)
1 (7)
0 (0)
4 (67)
1 (17)
Anemia
5 (33)
1 (7)
2 (14)
0 (0)
4 (67)
1 (17)
Thrombocytopenia
2 (13)
0 (0)
0 (0)
0 (0)
6 (100)
2 (33)
Hematologic
Febrile neutropenia
NR
NR
NR
NR
1 (17)
1 (17)
Fatigue / Malaise
10 (67)
2 (13)
10 (71)
0 (0)
3 (50)
0 (0)
Decreased appetite
5 (33)
1 (7)
2 (14)
0 (0)
5 (83)
0 (0)
Pyrexia
2 (13)
0 (0)
1 (7)
0 (0)
1 (17)
0 (0)
Arthralgia
7 (47)
0 (0)
2 (14)
0 (0)
4 (67)
0 (0)
Peripheral neuropathy
1 (7)
0 (0)
7 (50)
0 (0)
4 (67)
0 (0)
Gastrointestinal
Diarrhea
5 (33)
1 (7)
3 (21)
0 (0)
2 (33)
0 (0)

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Constipation
3 (20)
0 (0)
3 (21)
0 (0)
4 (67)
0 (0)
Nausea
2 (13)
0 (0)
6 (43)
0 (0)
4 (67)
0 (0)
Vomiting
0 (0)
0 (0)
2 (14)
0 (0)
1 (17)
0 (0)
Hypothyroidism
0 (0)
0 (0)
1 (7)
0 (0)
0 (0)
0 (0)
Endocrine
Hypophysitis
NR
NR
NR
NR
0 (0)
0 (0)
Increased ALT
0 (0)
0 (0)
0 (0)
0 (0)
3 (50)
0 (0)
Hepatic
Increased AST
0 (0)
0 (0)
0 (0)
0 (0)
2 (33)
0 (0)
Pulmonary
Pneumonitis
0 (0)
0 (0)
2 (14)
1 (7)
0 (0)
0 (0)
Renal
Increased serum 
creatinine
1 (7)
0 (0)
1 (7)
0 (0)
1 (17)
0 (0)
Pruritus
4 (27)
0 (0)
0 (0)
0 (0)
5 (83)
0 (0)
Rash
4 (27)
0 (0)
5 (36)
1 (7)
3 (50)
0 (0)
Maculopapular rash
2 (13)
2 (13)
0 (0)
0 (0)
1 (17)
0 (0)
Skin/Mucosa
Stomatitis
1 (7)
0 (0)
3 (21)
0 (0)
2 (33)
0 (0)
Epistaxis
2 (13)
0 (0)
0 (0)
0 (0)
4 (67)
0 (0)
Hypersensitivity 
4 (27)
0 (0)
0 (0)
0 (0)
1 (17)
0 (0)
Infusion-related reaction
2 (13)
0 (0)
0 (0)
0 (0)
1 (17)
0 (0)
*CA209-012 (Rizvi, JCO 2016); ** JapicCTI-132071 (Randa, Ann Oncol 2016)
2.6.5
Safety of the Combination of Nab-Paclitaxel and Nivolumab
For patients who are randomized to Arm B, carboplatin monotherapy as first-line metastatic 
treatment, the option of crossover to receive nab-paclitaxel plus nivolumab may be considered at 
the time of progression on carboplatin. Several trials have explored nab-paclitaxel-based regimens 
in combination with nivolumab across different tumor types.
In a phase I trial assessing nivolumab (3mg/kg Q2W) with nab-paclitaxel (125mg/m2 on days 1,8 
and 15, every 28-day cycle) plus or minus gemcitabine in advanced pancreatic cancer 
(NCT02309177), safety data from a total of 50 treatment-naïve patients were reported(88). One 
DLT was identified (hepatitis, evidenced by grade 3 elevated liver function tests that were 
considered to be related to nab-paclitaxel plus gemcitabine). Across all treated patients, 48 (96%) 
had at least one grade 3-4 treatment-related adverse event; the most common G3-4 events were 
anemia (36%), neutropenia (36%), gastrointestinal events (24%), hepatotoxicity (22%), peripheral 
neuropathy (16%), thrombocytopenia (12%) and colitis (12%). One grade 5 event, respiratory 
failure (considered most likely pneumonitis) was observed.
In a separate cohort of this phase I trial (NCT02309177) for stage IIIB/IV NSCLC, patients 
received nab-paclitaxel (100mg/m2 on days 1, 8 and 15) plus carboplatin plus nivolumab (5mg/kg 
day 15 of each 21-day cycle), followed by single-agent nivolumab as maintenance therapy starting 
in cycle 5(89). In the first 6 patients treated with the triplet combination, no DLTs were observed. 
Of the total 20 patients who received the triplet, the most common grade 3-4 treatment-related 
adverse events were neutropenia (45%) and anemia (40%). Grade 3 or 4 colitis or pneumonitis 
was not observed.
These results suggest that nivolumab plus nab-paclitaxel and another chemotherapeutic agent is 
tolerable; thus, the combination of only nab-paclitaxel and nivolumab is anticipated to have an 
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2.7
Correlative Studies Background 
2.7.1
Immune Marker Profiling
The importance of the tumor microenvironment and immunosurveillance in the natural 
history of cancer and response to therapy has become patent over the last years. This has led to 
improvement of clinical outcomes and U.S. FDA approval of immune checkpoint inhibitors for 
the treatment of various tumor types(90). However, less than half of patients with solid tumors 
derive benefit from these drugs (91, 92). Thus, it is crucial to elucidate the exact mechanisms of 
antitumor immunity evasion ongoing in the tumor microenvironment, in order to successfully 
develop new strategies that may enhance the effect of immunotherapeutic drugs.
Growing evidence suggests that patients with advanced solid tumors show differences in tumor 
microenvironment regarding the presence or absence of a gene expression profile indicative of a 
pre-existing T-cell–inflamed tumor microenvironment(93). Tumors classified as T-cell inflamed 
present a significant infiltration of CD8+ T cells and a type-I interferon (IFN) signature. In this 
group, the main mechanisms of immune evasion are the overexpression of immunosupressive 
molecules acting at the level of the tumor microenvironment, such as immune checkpoint 
molecules (CTLA-4, PD-1/PD-L1, TIM-3, LAG-3), indoleamine-2,3-dioxygenase (IDO), and 
FoxP3. Interestingly, these immunosuppressive molecules seem to be upregulated after 
deflagration of a type-I IFN antitumor response, resulting in T-cell exhaustion, and adaptive 
immune resistance(93, 94). In contrast, other tumors are characterized by low or absent 
intratumoral CD8 T cells and no evidence of a type-I IFN transcriptional signature; this tumor 
phenotype is non-T-cell-inflamed(93).
The T-cell inflamed phenotype has positive prognostic value for several types of early stage 
cancer, including breast cancer(58, 95), suggesting that an attempt by the host to generate an anti-
tumor immune response reflects a biologic process associated with improved patient 
outcomes(93). In breast oncology, different groups have demonstrated that the amount of TILs in 
a tumor specimen, commonly assessed by histological evaluation of a standard hematoxylin and 
eosin-stained slide by a trained pathologist, is a significant predictor of both response to therapy 
and overall disease outcomes in the neoadjuvant and adjuvant settings (36, 37, 55, 57, 96-98). 
Recently, more in-depth methods of immunologic profiling are being explored in breast cancer, 
for example mRNA expression of immune-activating and immunosuppressive factors, and these 
additional immune profiles also appear to have prognostic significance(95). Furthermore, in the 
metastatic setting, the phenotype T-cell-inflamed appears to be associated with clinical response 
to several immunotherapies, including checkpoint blockade(99). Patients with this tumor 
phenotype seem to be good candidates for immune checkpoint inhibitor therapy, alone or in 
combination. Thus, one of the main objectives of our correlative science in this trial is the 
characterization of a broad array of immune markers in metastatic TNBC, investigating whether 
these markers may predict disease response to therapy.
Considering the mechanism of action of anti-PD-1/anti-PD-L1 drugs, the absence of significant T-
cell infiltrate, in addition to low expression of immune checkpoint molecules, may correlate with 
a non-inflamed tumor phenotype that is associated with de novo resistance to these agents. For this 
group of patients, therapeutic strategies that promote an increase in cytotoxic T-cell infiltration, 

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such as chemotherapy, may be crucial to successfully overcoming T-cell exclusion and improve 
the likelihood of benefit of PD-1 blockade. 
Additionally, as part of the correlative work in this study, we will characterize the immune marker 
profile of peripheral blood mononuclear cells (PBMCs) in enrolled breast cancer patients. 
Furthermore, given the demonstrated clinical significance of TILs in breast cancer specimens, we 
will investigate whether there is a peripheral marker whose level corresponds to TIL infiltration. 
We will also evaluate whether there is a correlation between changes in PBMC immune profiles 
and response to treatment. Evidence of a correlation would be of significant interest as it would 
suggest the potential presence of a predictive biomarker of response or resistance in the peripheral 
blood.
2.7.2
Microbiota and Response to Immune Checkpoint Inhibitors 
The gut microbiota has been recognized as a modulator of immune system development(100). 
Healthy individuals have microbial populations in their intestinal tract that vary markedly in 
composition(101, 102). The diversity of intestinal microbiota represents a significant challenge to 
the host’s immune system, responsible for the balance between immune tolerance of beneficial 
microbes and inflammatory responses against pathogens. Alterations in the gut microbiota and 
their resulting interactions with intestinal epithelium and the host immune system are associated 
with many diseases, including cancer(103). Preclinical studies have provided strong evidence for 
the role of gut microbiota in modulating response and resistance to immune checkpoint inhibitors, 
raising the possibility that stool microbiota could be used as a predictive biomarker of efficacy to 
immunotherapy(104, 105). Interestingly, postmenopausal women with breast cancer have altered 
composition and low diversity of their gut microbiota compared to healthy controls, as measured 
by the Shannon index(106). 
Emerging evidence suggests that the gut microbiome may influence response to checkpoint 
inhibitors in a number of malignancies(14, 107-109). Preclinical studies in murine models have 
demonstrated that microbiome composition is associated with response to PD-L1 inhibitors, with 
mice exhibiting a “favorable” microbiome having a greater likelihood of responding to treatment 
as compared to mice with an “unfavorable” microbiome. Studies also demonstrate that 
transplanting feces from mice with favorable microbiota to those with unfavorable microbiota 
increases response rates, suggesting that modification of the microbiome could have a therapeutic 
effect in patients receiving checkpoint inhibitors(14). Translational work demonstrates that fecal 
transplants from patients responding to checkpoint inhibitors to nude mice increases the likelihood 
of response to immunotherapy in these animals, whereas transplants from human non-responders 
leads to a lower likelihood of response(14, 108). The evidence linking the gut microbiome to 
checkpoint inhibitor efficacy in humans has been relatively limited to date, but a number of recent 
publications have demonstrated a relationship between composition of the microbiome and 
response to immunotherapy in melanoma, non-small cell lung carcinoma and renal cell cancer(14, 
107-109). Notably, the bacterial species associated with a favorable response to treatment have 
differed across disease sites and studies(107, 109).
Microbiome composition is influenced by many factors, including age, genetics, and use of 
antibiotics and probiotics.(110-112). Studies demonstrate that dietary composition is one of the 

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primary drivers of microbiome diversity and taxa(110, 111). Other factors related to energy 
balance, the balance of calories ingested versus expended, such as physical activity and body 
weight also impact microbiome composition(111, 112). Limited data in humans suggest that 
factors impacting microbiome composition may also be related to checkpoint inhibitor response. 
An analysis of 113 patients with metastatic melanoma found significant associations between 
dietary factors (ingestion of red meat [p=0.006], sugar-sweetened beverages [p=0.048] and 
fruits/vegetables [p=0.049]) and microbiome composition(113). Use of antibiotics (p=0.05) and 
probiotics (p=0.02) was also associated with lower microbiome -diversity. Exploratory analyses 
of 46 of these patients who were initiating treatment with anti-PD-1 therapy suggested that 
individuals in this cohort with a higher consumption of dietary fiber had a 5-fold likelihood of 
response to anti-PD-1 therapy as compared to individuals with low fiber consumption (personal 
communication, Wargo). These findings are provocative, but were based on a dietary screening 
tool that provides a relative crude assessment of dietary intake. The study also did not assess other 
modifiable factors that can influence microbiome composition, such as physical activity, 
precluding identification of an optimal strategy of lifestyle modification to enhance 
immunotherapy response.
Identification of biomarkers that predict response to immunotherapies could potentially spare de 
novo resistant patients from the unnecessary risks of immune-related adverse events. In addition, 
the identification of bacterial species associated with response could open new strategies to 
maximize the clinical benefit of cancer immunotherapy through the modulation of gut microbiota.
In an effort to identify predictive biomarkers of response or resistance to immune checkpoint 
inhibitors, stool samples will be collected to determine whether baseline characteristics of the 
structure of the gut microbiome or changes in the overall diversity of gut microbiome are 
associated with efficacy of nivolumab in combination with carboplatin, in patients with metastatic 
TNBC. Additionally, to identify potentially modifiable drivers of microbiome diversity and 
composition, participants will undergo assessment of dietary composition, physical activity and 
body mass index at the same time points. 
These correlative projects are made possible by collaboration with Drs. Scott Rodig, Eliezer Van 
Allen, Peter Sorger and Mariano Severgnini, all of whom are laboratory scientists with extensive 
experience with immune profiling in melanoma. Further details can be found in Section 9.
3. PARTICIPANT SELECTION
Eligibility will be assessed as part of the screening procedures for all patients.
3.1
Eligibility Criteria
3.1.1
Participants must have histologically or cytologically confirmed invasive breast cancer, 
with unresectable locally advanced or metastatic disease. Participants without pathologic 
or cytologic confirmation of metastatic disease should have unequivocal evidence of 
metastasis from physical examination or radiologic evaluation.

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3.1.2
Estrogen-receptor and progesterone-receptor expression both ≤ 1% by 
immunohistochemistry (IHC), and HER2-negative status as determined by the current 
ASCO/CAP guidelines. If a patient has more than one histological result, the most recent 
sample will be considered for inclusion.
3.1.3
Participants must have PD-L1 status available at the time of registration. Standard local 
testing with any PD-L1 antibody that has been validated in a CLIA-certified environment 
will be acceptable for including patients on trial. Primary or metastatic samples may be 
tested for PD-L1 status.
3.1.4
Participants must have measurable or evaluable disease by RECIST version 1.1.
3.1.5
Participants must agree to undergo a research biopsy, if tumor is safely accessible, at 
baseline. Previously collected archival tissue will also be obtained on all participants. For 
participants for whom newly-obtained samples cannot be provided (e.g. inaccessible or 
participant safety concern) the archival tissue alone will be acceptable. Tissue needs to be 
located and availability confirmed at time of registration (See Section 9 for more details). 
Participants must agree to a mandatory repeat biopsy 3-6 weeks after starting treatment, if 
tumor is safely accessible. For patients randomized to carboplatin alone who decide to 
crossover to nivolumab + nab-paclitaxel at time of progression, a mandatory biopsy will 
be required, if tumor is safely accessible, prior to initiating crossover treatment; 
participants must also agree to undergo this biopsy, if applicable.
3.1.6
Prior chemotherapy: Participants must have received 0 prior chemotherapeutic regimens 
for metastatic breast cancer. Prior platinum in the neo/adjuvant setting is permissible, if at 
least 6 months elapsed since the end of adjuvant systemic therapy to the development of 
metastatic disease. All toxicities related to prior chemotherapy must have resolved to 
CTCAE v4.0 grade 1 or lower, unless otherwise specified in 3.1.10.
3.1.7
Prior biologic therapy: Prior poly-ADP ribose polymerase (PARP) inhibitors are not 
allowed in the metastatic setting. Prior PARP inhibitors in the neo/adjuvant setting are 
permissible, if at least 6 months elapsed since the end of adjuvant systemic therapy to the 
development of metastatic disease. All toxicities related to prior biologic therapy must 
have resolved to CTCAE v4.0 grade 1 or lower, unless otherwise specified in 3.1.11.
3.1.8
Prior radiation therapy: Patients may have received prior radiation therapy. Radiation 
therapy must be completed at least 7 days prior to registration, and all toxicities related to 
prior radiation therapy must have resolved to CTCAE v4.0 grade 1 or lower, unless 
otherwise specified in 3.1.11. Patients may not have had >25% of their bone marrow 
radiated.
3.1.9
The subject is 18 years old.

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3.1.10 ECOG performance status ≤1 (Karnofsky >60%, see Appendix A).
3.1.11 Participants must have normal organ and marrow function as defined below:

Absolute neutrophil count
≥1,500/mcL

Platelets
≥100,000/mcL

Hemoglobin 
≥ 9.0 g/dl

Total bilirubin
≤1.5 × institutional upper limit of normal (ULN)
 (or ≤2.0 x ULN in patients with documented 
Gilbert’s Syndrome)

AST(SGOT)/ALT(SGPT)
≤2.5 × institutional ULN or 
≤5 × institutional ULN for participants with 
documented liver metastases

Serum creatinine 
≤1.5 × institutional ULN OR creatinine clearance ≥ 
45 mL/min/ 1.73m2 for participants with creatinine 
levels above institutional ULN.
Note: Supportive care (e.g. transfusion of red blood cells) is allowed to meet eligibility 
criteria.
3.1.12 Female subjects of childbearing potential must have a negative serum or urine pregnancy 
test within 2 weeks prior to registration.
Childbearing potential is defined as: participants who have not reached a postmenopausal 
state (≥ 12 continuous months of amenorrhea with no identified cause other than 
menopause) and have not undergone surgical sterilization (removal of ovaries and/or 
uterus).
3.1.13 Women of childbearing potential (WOCBP) must agree to use an adequate method of 
contraception.  Contraception is required starting with the first dose of study medication 
through 150 days (5 months) after the last dose of study medication. Examples of 
contraceptive methods with a failure rate of < 1% per year include bilateral tubal ligation, 
male sterilization, established and proper use of hormonal contraceptives that inhibit 
ovulation, hormone-releasing intrauterine devices, and copper intrauterine devices. 
Periodic abstinence (e.g., calendar, ovulation, symptothermal, or postovulation methods) 
and withdrawal are not acceptable methods of contraception.

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3.1.14 Males who are sexually active with WOCBP must agree to follow instructions for 
method(s) of contraception for the duration of study treatment with nivolumab and 7 
months after the last dose of study treatment (i.e., 90 days (duration of sperm turnover) 
plus the time required for the investigational drug to undergo approximately five half-
lives.)
3.1.15 Participants on bisphosphonates or RANK ligand inhibitors may continue receiving 
therapy during study treatment.
3.1.16 The participant must be capable of understanding and complying with the protocol and 
willing to sign a written informed consent document.
3.2
Exclusion Criteria
3.2.1
Concurrent administration of any other anti-cancer therapy during the course of this study 
(bisphosphonates and RANK ligand inhibitors are allowed).
3.2.2
Prior hypersensitivity to platinum chemotherapy or to any of the excipients of platinum 
or nivolumab therapy. 
3.2.3
Prior therapy with an anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CD137, or anti-Cytotoxic 
T-lymphocyte-associated antigen-4 (CTLA-4) antibody (including pembrolizumab, 
ipilimumab, and any other antibody or drug specifically targeting T-cell co-stimulation or 
checkpoint pathways).
3.2.4
Known brain metastases that are untreated, symptomatic, or require therapy to control 
symptoms. Participants with a history of treated central nervous system (CNS) metastases 
are eligible. Treated brain metastases are defined as those without ongoing requirement 
for corticosteroids, as ascertained by clinical examination and brain imaging (magnetic 
resonance imaging or CT scan) completed during screening. Any corticosteroid use for 
brain metastases must have been discontinued without the subsequent appearance of 
symptoms for ≥ 7 days prior to registration. Treatment for brain metastases may include 
whole brain radiotherapy, radiosurgery, surgery or a combination as deemed appropriate 
by the treating physician. Radiation therapy must be completed at least 7 days prior to 
registration, as specified in Section 3.1.8.
3.2.5
Major surgery within 2 weeks prior to registration. Patients must have recovered from 
any effects of any major surgery.
3.2.6
Uncontrolled, significant intercurrent or recent illness including, but not limited to, 
ongoing or active infection, uncontrolled non-malignant systemic disease, uncontrolled 
seizures, or psychiatric illness/social situation that would limit compliance with study 
requirements in the opinion of the treating investigator. 

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3.2.7
Participant has a medical condition that requires chronic systemic steroid therapy (> 10 
mg of prednisone daily or equivalent) or any other form of immunosuppressive 
medication (including disease modifying agents) and has required such therapy in the last 
2 years. Replacement therapy (eg., thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form 
of systemic therapy.
3.2.8
Participant has documented history of autoimmune disease or syndrome that currently 
requires systemic steroids or immunosuppressive agents.
3.2.9
History or evidence of active, non-infectious pneumonitis or interstitial lung disease.
3.2.10 Individuals with a history of a second malignancy are ineligible except for the following 
circumstances. Individuals with a history of other malignancies are eligible if they have 
been disease-free for at least 3 years or are deemed by the investigator to be at low risk 
for recurrence of that malignancy. Individuals with the following cancers that have been 
diagnosed and treated within the past 3 years are eligible: cervical/prostate carcinoma in 
situ, superficial bladder cancer, non-melanoma cancer of the skin. Patients with other 
cancers diagnosed within the past 3 years and felt to be at low risk of recurrence should 
be discussed with the study sponsor to determine eligibility.
3.2.11 Participant is known to be positive for the human immunodeficiency virus (HIV), 
HepBsAg, or HCV RNA. HIV-positive participants are ineligible because of the potential 
for pharmacokinetic interactions of combination antiretroviral therapy with study drugs. 
In addition, these participants are at increased risk of fatal infections when treated with 
marrow-suppressive therapy.
3.2.12 The participant has received a live vaccine within 28 days prior to registration. Examples 
of live vaccines include, but are not limited to, the following: measles, mumps, rubella, 
varicella/zoster, yellow fever, rabies, BCG, and typhoid vaccine. The use of the 
inactivated seasonal influenza vaccine is allowed.
3.2.13 Women who are pregnant or breastfeeding or adults of reproductive potential not 
employing an adequate method of contraception. 
Childbearing potential is defined as: participants who have not reached a postmenopausal 
state (≥ 12 continuous months of amenorrhea with no identified cause other than 
menopause) and have not undergone surgical sterilization (removal of ovaries and/or 
uterus).
Inclusion of Women and Minorities
Both men and women of all races and ethnic groups are eligible for this trial.

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4. REGISTRATION PROCEDURES
4.1
General Guidelines for DF/HCC Institutions
Institutions will register eligible participants in the Clinical Trials Management System (CTMS) 
OnCore via the Office of Data Quality. Registrations must occur prior to the initiation of protocol 
therapy. Any participant not registered to the protocol before protocol therapy begins will be 
considered ineligible and registration will be denied. An investigator will confirm eligibility 
criteria and a member of the study team will complete the protocol-specific eligibility checklist. 
Following registration, participants may begin protocol therapy. Issues that would cause treatment 
delays should be discussed with the Overall Principal Investigator (PI). If a participant does not 
receive protocol therapy following registration, the participant’s registration on the study must be 
canceled. Registration cancellations must be made in OnCore as soon as possible. 
4.2
Registration Process for DF/HCC Institutions 
DF/HCC Standard Operating Procedure for Human Subject Research Titled Subject Protocol 
Registration (SOP #: REGIST-101) must be followed.  
4.3
General Guidelines for Other Investigative Sites 
Eligible participants will be entered on study centrally at the Coordinating Center through the 
Study Coordinator or Project Manager. The list of required forms can be found in Section 4.4.  
Following registration, it is recommended that participants begin protocol therapy within 7 days. 
Issues that would cause treatment delays should be discussed with the Overall PI.  If a participant 
does not receive protocol therapy following registration, the participant’s registration on the study 
must be canceled.  The Study Coordinator should be notified of cancellations as soon as possible.
4.4
Registration Process for Other Investigative Sites
To register a participant, the following documents should be completed by the research nurse or 
data manager and faxed to 617-632-5152 or e-mailed to ctopm@dfci.harvard.edu to the Study 
Coordinator:

Signed participant consent form

HIPAA authorization form

Eligibility Checklist

Pathology reports documenting receptor status and PD-L1 status

Baseline exam note including medical/surgical history, ECOG, vital signs

EKG report

Laboratory report including hematology, chemistries, PT/PTT, and pregnancy test

Tumor Assessment report (C/A/P CT and/or MRI)

Brain MRI report (if applicable)

Documentation of tissue availability (per eligibility criteria 3.1.4)

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To complete the registration process, the Coordinator or Project Manager will follow DF/HCC 
Standard Operating Procedure for Human Subject Research Titled Subject Protocol Registration 
(SOP #: REGIST-101) and register the participant on the protocol.  The coordinator will fax or e-
mail the participant study number, and if applicable the dose treatment level, to the participating 
site.  
NOTE: Registration and randomization can only be conducted during the business hours of 
8:00 AM and 5:00 PM Eastern Standard Time Monday through Friday. Same day treatment 
registrations will only be accepted with prior notice and discussion with the DF/HCC Lead 
Institution. 
5. TREATMENT PLAN
5.1
Treatment Regimen
This is an open-label, randomized, phase II study of carboplatin at a dose of AUC 6 given with or 
without nivolumab 360 mg intravenously, every 3 weeks. One hundred and thirty-two  participants 
will be enrolled to the study to compare the efficacy of the combination to carboplatin alone, 
defined by PFS, as first-line therapy in patients with metastatic TNBC.
Treatment will be administered on an outpatient basis. Reported adverse events and potential risks 
are described in Section 7.  Appropriate dose modifications are described in Section 6. No 
investigational or commercial agents of therapies other than those described below may be 
administered with the intent to treat the participant’s malignancy.
Regimen Description
Agent
Premedication; 
Precautions
Dose
Route Schedule
Cycle 
length
Infusion
Observation 
period post-
infusion
Arm A 
Nivolumab
(BMS-936558-01)
Not routinely 
necessary unless 
prior infusion 
reaction.
360 mg
IV
Every 3 
weeks
21 days
(3 weeks)
Over 30 min 
(+/- 10 min)
30 min 
(+/- 10 min)
Carboplatin
Dexamethasone 
4 mg IV is 
recommended 
(See Section 5.3).
AUC 6
IV
Every 3 
weeks
21 days
(3 weeks)
Per institutional 
guidelines 
(Recommended
: 30-60min).
Per 
institutional 
guidelines.
Arm B 
Carboplatin
Dexamethasone 
4 mg IV is 
recommended 
(See Section 5.3).
AUC 6
IV
Every 3 
weeks
21 days
(3 weeks)
Per institutional 
guidelines 
(Recommended
: 30-60min).
Per 
institutional 
guidelines.

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5.2
Pre-Treatment Criteria
5.2.1
Cycle 1, Day 1
Participants do not need to re-meet eligibility criteria on Cycle 1, Day 1.

Absolute neutrophil count
≥ 1,000/mcL

Platelets
≥ 75,000/mcL

Hemoglobin 
≥ 9 g/dl

Total bilirubin
≤ 1.5 × institutional upper limit of normal (ULN) 
(or ≤ 2.0 x ULN in patients with documented Gilbert’s 
Syndrome)

AST(SGOT)/ALT(SGPT)
≤ 2.5 × institutional ULN or ≤ 5 × institutional ULN for
 participants with documented liver metastases

Creatinine
≤1.5 × institutional ULN OR creatinine clearance ≥ 45 
mL/min/1.73 m2 for participants with creatinine levels 
above institutional ULN.
5.2.2
Subsequent Cycles, Day 1 

Absolute neutrophil count
≥ 1,000/mcL

Platelets
≥ 75,000/mcL

Total bilirubin
≤ 1.5 × institutional ULN (or ≤ 2.0 x ULN in patients 
with documented Gilbert’s Syndrome)

AST(SGOT)/ALT(SGPT)
≤ 3.0 × institutional ULN or ≤ 5 × institutional ULN for 
participants with documented liver metastases

Creatinine
≤2.0 × institutional ULN OR creatinine clearance ≥ 30 
mL/min/1.73 m2 for participants with creatinine levels 
above institutional ULN.
Please see Section 6.1 regarding dose delays and discontinuation. 
5.3
Agent Administration
Nivolumab infusion and observation period after nivolumab should be completed prior to the 
administration of carboplatin when both drugs are administered on the same day of each cycle.
5.3.1
Nivolumab Administration
Nivolumab will be administered every three weeks +/- 4 days at a dose of 360 mg given 
intravenously over approximately 30 minutes (+/- 10 minutes) using a volumetric pump with 0.2 
to 1.2 micrometer pore size, low-protein binding polyethersulfone membrane in-line filter. There 
will be an observation period of 30 minutes after the end of the nivolumab infusion. Dosing of 
nivolumab should be until progression or unacceptable toxicity. Please see section 2.5.2 for 
information regarding the rationale for the dose of nivolumab, and 2.5.3 for the rationale for shorter 
infusion time for nivolumab.

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Please see section 5.7 for information on Second Course Phase: Retreatment and Crossover 
therapy. For patients randomized to Arm B (carboplatin alone) who elect to crossover at the time 
of progression to receive nab-paclitaxel plus nivolumab, nivolumab will be administered every 4 
weeks at a dose of 480 mg intravenously over approximately 30 minutes (+/- 10 minutes). There 
will be an observation period of 30 minutes after the end of the nivolumab infusion. Nivolumab 
will be administered prior to nab-paclitaxel.
5.3.2
Carboplatin Administration
The dose of carboplatin in this study is AUC of 6 mg/mL*min administered by IV infusion per 
institutional standard practice (recommended infusion time of approximately 30 to 60 minutes). 
Observation period after carboplatin administration will follow institutional guidelines.
Dose will be based on the Calvert formula:
Carboplatin dose (mg) = AUC × (GFR + 25) where GFR is glomerular filtration rate
Maximum carboplatin dose (mg) = target AUC (mg/mL • min) × (150 mL/min)
GFR is estimated using the Cockcroft–Gault formula for creatinine clearance:
(140 − age) × (weight in kg) × (0.85 if female)
72 × (serum creatinine in mg/dL)
The total dose of carboplatin for each patient will be per institutional guidelines. Carboplatin 
should be administered after nivolumab.
No premedication is usually required although 4 mg of dexamethasone IV (administered 30 min 
prior to carboplatin) are recommended to avoid hypersensitivity reactions, at physician´s 
discretion. If a patient was previously pretreated with carboplatin and there has been more than a 
6 month gap between courses of treatment, chlorphenamine 10mg IV + hydrocortisone 100mg 
IV should be given due to a possible reaction to carboplatin antibodies.
Carboplatin as well as premedication is to be administered and stored in accordance with local 
prescribing information and local institutional guidelines. For further details, see the carboplatin 
Package Insert or Summary of Product Characteristics.
NOTE: Aluminum reacts with carboplatin causing precipitate formation and loss of potency, 
therefore, needles or intravenous sets containing aluminum parts that may come in contact 
with the drug must not be used for the preparation or administration of carboplatin.
5.3.3
Nab-paclitaxel Administration
Nab-paclitaxel is administered in the Crossover phase of second course treatment (See Section 
5.7). 

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Please refer to the FDA-approved package insert for nab-paclitaxel for product information, 
extensive preparation instructions, and comprehensive list of adverse events. 
Nab-paclitaxel will be administered on Days 1, 8, and 15 of every 28 day (4 week)-cycle. Nab-
paclitaxel will be administered as an intravenous infusion over 30 minutes after the nivolumab 
infusion and observation window is complete. Filters are not required for preparation or 
administration of nab-paclitaxel. If filters are used as part of institutional procedure, the pore size 
must be ≥ 15 microns.
5.4
Definition of Dose-Limiting Toxicity (DLT) 
We will perform a safety run-in analysis on the first 12 participants enrolled to the experimental 
arm (Arm A) of the trial. If there are 4 or more dose-limiting toxicity (DLTs) in the first 12 
participants, enrollment will be halted to discuss whether the study will be amended, with re-
evaluation of the appropriate dosing schedule and study design, or closed.
Additionally, we will perform a safety run-in analysis in the first 12 participants who crossover to 
nivolumab + nab-paclitaxel. If there are 4 or more dose-limiting toxicity (DLTs) in the first 12 
participants treated with nivolumab + nab-paclitaxel, crossover will be halted to discuss whether 
the study will be amended, with re-evaluation of the appropriate crossover dosing schedule and 
design, or the option to crossover closed. 
A DLT is defined as an IP-related AE(s) (attributed to nivolumab and/or the combination of 
nivolumab plus carboplatin) occurring during the DLT assessment period (the first 21-day cycle 
of concurrent carboplatin and nivolumab in Arm A; the first 28-day cycle of nivolumab + nab-
paclitaxel crossover treatment), if judged by the investigator to be possibly, probably, or definitely 
related to study drug administration, that meets one of the following criteria:

Any grade 5 toxicity

Grade 3 thrombocytopenia if associated with clinically significant bleeding requiring 
medical intervention or 

Grade 4 thrombocytopenia of any duration

Grade 4 neutropenia lasting ≥ 7 days

≥ Grade 3 febrile neutropenia

Any other grade 4 hematologic toxicity lasting ≥ 14 days, unless deemed by the 
investigator to be clinically insignificant

≥ Grade 3 AST or ALT elevation  of any duration, or ≥ Grade 3 AST or ALT elevation 
lasting ≥ 7 days in patients with documented liver metastases

Grade 2 bilirubin elevation (except bilirubin > 3 x ULN in patients with documented 
Gilbert´s syndrome)

Cases of Hy’s Law

Any ≥ Grade 3 non-hematologic toxicity:
Excluding:

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
≥ Grade 3 electrolyte abnormalities that lasts <24 to 72 hours, are not 
clinically complicated, and resolve spontaneously or respond to 
conventional medical interventions 

≥ Grade 3 amylase or lipase that is not associated with symptoms or 
clinical manifestations of pancreatitis

Grade 3 nausea/vomiting or diarrhea < 72 hours with adequate antiemetic 
and other supportive care      

Grade 3 fatigue < 7 days

Alopecia of any grade

Any Grade 2 treatment-related pneumonitis or interstitial lung disease that did not resolve 
with dose delay and systemic steroids to ≤ Grade 1 within 14 days.

> Grade 3 other non-laboratory toxicity lasting > 5 days despite optimal supportive care, 
excluding alopecia of any grade
Management and dose modifications associated with the above adverse events are outlined in 
Section 6.
5.5
Definition of Potential Drug Induced Liver Injury (DILI)
Definition of drug induced liver injury (DILI) criteria is mandatory for all pre-marketed asset 
protocols enrolling participants without known abnormalities in liver function at baseline AND for 
protocols involving participants with known liver abnormalities at baseline or with other clinical 
confounders where asset specific criteria for potential drug induced liver injury have been defined. 
All occurrences of potential DILIs, meeting the defined criteria, must be reported as SAEs.
In participants without known abnormalities in liver function at baseline, potential DILI is 
defined as:
1)      ALT or AST elevation > 3 times upper limit of normal (ULN)
AND
2)      Total bilirubin > 2 times ULN, without initial findings of cholestasis (elevated serum 
alkaline phosphatase)
AND
3)      No other immediately apparent possible causes of AST or ALT 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.
In participants with known abnormalities in liver function at baseline (e.g. liver metastases), or 
with other clinical counfounders (e.g. Gilbert´s disease), potential DILI is defined as:
1)      ALT or AST elevation > 5 times upper limit of normal (ULN)
AND
2)      Total bilirubin > 3 times ULN, without initial findings of cholestasis (elevated serum 
alkaline phosphatase)
AND
3)      No other immediately apparent possible causes of increase in AST or ALT elevation and 
hyperbilirubinemia, including, but not limited to, viral hepatitis, pre-existing chronic or acute 

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liver disease, or the administration of other drug(s) known to be hepatotoxic.
5.6
General Concomitant Medication and Supportive Care Guidelines
5.6.1
Concomitant Medication Guidelines
Medications or vaccinations specifically prohibited in the exclusion criteria (3.2.12) are not 
allowed during the ongoing trial.  If there is a clinical indication for one of these or other 
medications or vaccinations specifically prohibited during the trial, discontinuation from trial 
therapy may be required.  The investigator should discuss any questions regarding this with the 
overall PI.
Acceptable Concomitant Medications
All treatments that the investigator considers necessary for a subject’s welfare may be administered 
at the discretion of the investigator in keeping with the community standards of medical care and 
documented in the medical record. All prior treatment or medication administered during the 28 
days preceding the first dose of trial treatment and any concomitant therapy administered to the 
subject throughout the study until 30 days after the last dose of trial treatment, including 
medication name and indication, will be captured. 
Prohibited Concomitant Medications
Subjects are prohibited from receiving the following therapies during the Screening (14 days prior 
to trial registration) and Treatment Phase(s) of this trial:

Antineoplastic systemic chemotherapy or biological therapy 

Immunotherapy not specified in this protocol

Investigational agents other than nivolumab

Radiation therapy (7 days prior to screening and during treatment)

Live vaccines within 28 days prior to the first dose of trial treatment and while participating 
in the trial.  Examples of live vaccines include, but are not limited to, the following: 
measles, mumps, rubella, varicella/zoster, yellow fever, rabies, BCG, and typhoid vaccine. 
The use of the inactivated seasonal vaccine is allowed.

Systemic glucocorticoids should be avoided for any purpose other than to modulate 
symptoms from radiation, prevent hypersensitivity reactions or an event of clinical interest 
of suspected immunologic etiology. If corticosteroids are required for this purpose, the 
minimum effective dose should be used.  The use of physiologic doses of corticosteroids 
(10 mg prednisone daily or equivalent) can be used without principal investigator (PI) 
authorization.

Subjects may receive other medications that the investigator deems to be medically 
necessary.

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For eligible patients who elect to crossover to nab-paclitaxel plus nivolumab, care should be taken 
with concomitant use of strong CYP3A4 inhibitors/inducers (e.g., ketoconazole and itraconazole) 
and nab-paclitaxel. An alternate medication with no or minimal potential to inhibit CYP3A4 
should be considered. If a strong CYP3A4 inhibitor is co-administered with nab-paclitaxel, 
participants should be closely monitored for adverse reactions.
The exclusion criteria section describes other medications which are prohibited in this trial.
There are no prohibited therapies during the Post-Treatment Follow-up Phase.
5.6.2
Supportive Care Guidelines – General Medications
The following treatments are permitted throughout the duration of the study Treatment Phase and 
during Follow-up:

Standard therapies for pre-existing medical conditions unless listed as prohibited therapy. 
Any medication intended solely for supportive care (e.g., analgesics, anti-diarrheal, anti-
depressants) may be used at the investigator’s discretion. Antiemetics and anti-diarrheal 
medications should not be administered prophylactically before initial treatment with study 
drugs. At the discretion of the investigator, prophylactic antiemetic and anti-diarrheal 
medication(s) may be used as per standard clinical practice before subsequent doses of 
study drugs or before, during or after radiation treatment:
o
Recommended prophylactic anti-emetic therapy for carboplatin include:

-Aprepitant 125 mg oral (1 capsule on the same day, to be administered 
approximately 60 minutes prior to carboplatin)

-Aprepitant 80 mg oral (1 capsule daily for 2 days, starting 24 hours after 
the administration of carboplatin)

-Palonosetron 0.25 mg IV (1 dose to be administered 30 minutes prior to 
carboplatin)

-Lorazepam 0.5-1.0 mg oral (every 4-6 hours if needed for anticipatory 
nausea or vomiting, or anxiety)

-Dexamethasone: Corticosteroids should be avoided unless deemed 
necessary to control refractory nausea or vomiting. If needed, administer 4 
mg oral (at the start of treatment) or 4mg IV (dose to be administered 30 
minutes prior to carboplatin)

Hematopoietic growth factors (e.g., G-CSF, granulocyte macrophage colony stimulating 
factor) may be used at investigator’s discretion for the primary prophylaxis and/or 
management of treatment-emergent neutropenia and/or for secondary prophylaxis as per 
NCCN/European Society for Medical Oncology guidelines or local standard practice.

Bisphosphonate or denosumab therapy to be used in accordance with the approved labeled 
indication and/or nationally recognized treatment guidelines. Participants already receiving 
bisphosphonate/denosumab at the time of study entry can continue the treatment. 
Participants may initiate treatment with bisphosphonate/denosumab after study entry with 
physician discretion.

Pain medications administered per standard clinical practice are acceptable while the 
patient is enrolled in the study.

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Patients who experience toxicities should be treated symptomatically as clinically indicated. 
Medications that are considered necessary for the subject’s welfare and that are not expected to 
interfere with the evaluation of study treatment or be restricted may be given at the discretion of 
the investigator.  Ancillary treatments will be given as medically indicated.
Potential Drug Interactions:
No formal pharmacokinetic drug-drug interaction studies have been conducted with nivolumab. 
The renal effects of nephrotoxic compounds (e.g., aminoglycoside antibiotics, diuretics) may be 
potentiated by carboplatin. Drugs that increase the risk of agranulocytosis (e.g., clozapine) should 
be avoided.
The following significant drug interactions have been reported with carboplatin:
Warfarin/cumarin anticoagulants: (unknown mechanism) Avoid if possible as use 
often causes an elevation or fluctuation in the INR – in the first instance, consider 
switching to a low molecular weight heparin during treatment or, if the patient 
continues taking an oral anticoagulant, monitor the INR at least once a week and 
adjust dose accordingly.
Clozapine: (additive) increased risk of agranulocytosis, avoid concomitant use
Phenytoin: reduced absorption of the antiepileptic
Diuretics, aminoglycoside antibiotics: (additive) increased risk of nephrotoxicity 
and ototoxicity
For eligible patients who elect to crossover to nab-paclitaxel plus nivolumab, caution should be 
exercised when administering nab-paclitaxel concomitantly with medicines known to inhibit or 
induce either CYP2C8 or CYP3A4. 
5.7
Criteria for Taking a Participant Off Protocol Therapy
Duration of therapy will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse event(s), treatment may continue until 
one of the following criteria applies:
1. Disease progression by RECIST 1.1 criteria:
A. Please note that, although the primary endpoint is PFS as defined by RECIST 1.1, 
patients may remain on protocol therapy until the time of disease progression by 
irRC criteria. The immune criteria allow treatment beyond initial radiographic 
worsening of disease in order to distinguish between pseudoprogression and true 
disease progression.
B. Participants who have attained a confirmed complete response (CR) that have been 
treated for at least 24 weeks on protocol therapy and had at least two treatments 
with nivolumab beyond the date when the initial CR was declared.  Participants 
who stop nivolumab with CR may be eligible for additional nivolumab therapy if 
they progress after stopping study treatment. This retreatment is termed the Second 
Course Phase Therapy. See additional details below.

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2. Intercurrent illness that prevents further administration of treatment.
3. Unacceptable adverse event(s).
4. Participant demonstrates an inability or unwillingness to comply with the medication 
regimen and/or documentation requirements.
5. Participant decides to withdraw from the protocol therapy.
6. General or specific changes in the participant’s condition render the participant 
unacceptable for further treatment in the judgment of the treating investigator.
Participants will be removed from the protocol therapy when any of these criteria apply.  The 
reason for removal from protocol therapy, and the date the participant was removed, must be 
documented in the case report form (CRF) and in the CTMS system (OnCore). Alternative care 
options will be discussed with the participant.
In the event of unusual or life-threatening complications, treating investigators must immediately 
notify the Overall PI, 
Second Course Phase:
A) Retreatment Phase
A1. Participants randomized to the experimental arm (Arm A) may elect to stop nivolumab and/or 
carboplatin with confirmed CR after at least 24 weeks of treatment.
Subjects who stop nivolumab with CR may be eligible for additional nivolumab therapy if they 
progress after stopping study treatment. This retreatment is termed the Second Course Phase of 
this study and is only available if the study remains open and the subject meets the following 
conditions:
o
Stopped initial treatment with nivolumab and carboplatin after attaining an 
investigator-assessed CR according to RECIST 1.1, confirmed in at least two 
consecutive restaging scans, was treated for at least 24 weeks with nivolumab before 
discontinuing therapy, and received at least two treatments with nivolumab beyond the 
date when the initial CR was declared
AND
o
Experienced an investigator-assessed confirmed radiographic disease progression after 
stopping their initial treatment with nivolumab
o
Did not receive any anti-cancer treatment other than carboplatin since the last dose of 
nivolumab
The retreatment section of the eligibility checklist should be completed and signed by the treating 

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investigator. DF/HCC sites will re-fax the checklist to ODQ for processing. Non-DF/HCC sites 
will fax or email documentation to the Coordinating Center at 617-632-5152 or 
ctopm@dfci.harvard.edu for review. Provided the patient meets criteria per protocol for 
retreatment, the Coordinating Center will process the checklist and the participating site will be 
notified that the patient may proceed to retreatment.
Subjects who restart treatment will be retreated at the same dose and dose interval as when they 
last received nivolumab. Visit requirements are as outlined for subjects on the initial treatment 
phase of the trial.
A2. Eligible participants who receive nab-paclitaxel and nivolumab during the Crossover phase 
(please see below) may elect to stop nivolumab and/or nab-paclitaxel with confirmed CR after at 
least 24 weeks of treatment. Subjects in the Crossover phase who stop nivolumab with CR may be 
eligible for additional nivolumab therapy if they progress after stopping study treatment. This 
retreatment is termed the Second Course Phase of this study and is only available if the study 
remains open and the subject meets the following conditions:
o
Stopped initial treatment with nivolumab and nab-paclitaxel after attaining an 
investigator-assessed CR according to RECIST 1.1, confirmed in at least two 
consecutive restaging scans, was treated for at least 24 weeks with nivolumab before 
discontinuing therapy, and received at least two treatments with nivolumab beyond the 
date when the initial CR was declared
AND
o
Experienced an investigator-assessed confirmed radiographic disease progression after 
stopping their initial treatment with nivolumab
o
Did not receive any anti-cancer treatment other than nab-paclitaxel since the last dose 
of nivolumab
The retreatment section of the eligibility checklist should be completed and signed by the treating 
investigator. DF/HCC sites will re-fax the checklist to ODQ for processing. Non-DF/HCC sites 
will fax or email documentation to the Coordinating Center at 617-632-5152 or 
ctopm@dfci.harvard.edu for review. Provided the patient meets criteria per protocol for 
retreatment, the Coordinating Center will process the checklist and the participating site will be 
notified that the patient may proceed to retreatment.
Subjects who restart treatment will be retreated at the same dose and dose interval as when they 
last received nivolumab. Visit requirements are as outlined for subjects on the crossover treatment 
phase of the trial.
B) Standard arm: Crossover Phase
If treatment is permanently discontinued due to disease progression (i.e. not due to toxicity) in a 
participant randomized to the standard arm of carboplatin alone, the patient will be offered the 
option to crossover to receive nivolumab at a dose of 480 mg intravenously every 4 weeks in 

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combination with nab-paclitaxel (Days 1, 8, 15 of every 28-day cycle) at a dose of 100 mg/m2, 
until documented disease progression per RECIST 1.1 criteria or unacceptable toxicity. This phase 
is considered part of the protocol therapy.
Regimen Description
Agent
Premedication
; Precautions
Dose
Route
Schedule
Cycle 
length
Infusion
Observation 
period post-
infusion
Crossover 
Nivolumab
(BMS-936558-01)
Not routinely 
necessary 
unless prior 
infusion 
reaction.
480 mg
IV
Every 4 
weeks
28 days 
(4 weeks)
Over 30 min 
(+/- 10 min)
30 min 
(+/- 10 min)
nab-Paclitaxel
Not routinely 
necessary 
unless prior 
infusion 
reaction.
100 
mg/m2
in NS*
IV
Day 1, 8, 
15
28 days 
(4 weeks)
30 minutes 
(+/- 10 min)
Start nab-paclitaxel 
after nivolumab 
infusion + 
observation 
window completed
Per 
institutional 
guidelines.
*Dose reductions may be made per Section 6.1. Further details about dose reductions can be found in Sections 6.4
**Limiting the infusion of nab-paclitaxel to 30 minutes, as directed, decreases the likelihood of infusion-related 
reactions.
Screening does not need to be repeated, however, patients must meet the following criteria to treat 
Day 1 of Crossover Therapy, and eligibility must be confirmed by the treating investigator:

ECOG performance status
≤ 2 (or Karnofsky ≥ 50%)

Absolute neutrophil count
≥ 1,000/mcL

Platelets
≥ 75,000/mcL

Peripheral neuropathy
≤ Grade 2

Total bilirubin
≤ 1.5 × institutional upper limit of normal (ULN) 
(or ≤ 2.0 x ULN in patients with documented Gilbert’s 
Syndrome)

AST(SGOT)/ALT(SGPT)
≤ 3.0 × institutional ULN or ≤ 5 × institutional ULN for
 participants with documented liver metastases

Negative pregnancy test within 7 days of the first dose of nivolumab

No clinically significant ECG abnormalities

No history or evidence of active, noninfectious pneumonitis that required treatment 
for steroids

Willing to undergo a mandatory research biopsy prior to initiation of nivolumab, if 
tumor is safely accessible for biopsy
Documents to support the above criteria, including the crossover section of the eligibility 

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checklist, should be completed and signed by the treating investigator. DF/HCC sites will re-fax 
the checklist to ODQ for processing. Non-DF/HCC will fax or email documentation to the 
Coordinating Center at 617-632-5152 or ctopm@dfci.harvard.edu for review. Provided the 
patient meets criteria per protocol for Crossover Therapy, the Coordinating Center will process 
the checklist and the participating site will be notified that the patient may proceed to Crossover 
Therapy. Please see the Crossover Study Calendar in Section 10 for guidance on visit 
requirements.  
5.8
Duration of Follow-Up
Participants will be followed on-study until death. 
Participants removed from protocol therapy for unacceptable adverse event(s) will be followed 
until resolution or stabilization of the adverse event. An additional adverse event assessment will 
be performed 100 days (-15/+30 days) after the last dose of treatment for participants who receive 
nivolumab. This may be conducted by phone.  
Participants who are alive and free of disease progression at the time of removal from protocol 
therapy will be followed for first disease progression event after removal from protocol therapy. 
Tumor assessments should continue to be performed every 6-12 weeks in these participants until 
first disease progression event or death, whichever occurs first. Research blood draws are optional 
at the time of tumor assessments. 
In follow-up, all participants, including those who came off protocol therapy due to progression, 
will be contacted every 6 months for survival and progression. Follow up visits start 6 months 
from the end of treatment visit. 
5.9
Criteria for Taking a Participant Off Study
Participants will be removed from study when any of the following criteria apply:

Lost to follow-up

Withdrawal of consent for data submission

Death
The reason for taking a participant off study, and the date the participant was removed, must be 
documented in the case report form (CRF). In addition, the study team will ensure Off 
Treatment/Off Study information is updated in OnCore in accordance with DF/HCC policy 
REGIST-101.
6. DOSING DELAYS/DOSE MODIFICATIONS
Dose delays and modifications will be made as indicated in the following table(s). The 
descriptions and grading scales found in the revised NCI Common Terminology Criteria for 

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Adverse Events (CTCAE) version 4.0 will be utilized for dose delays and dose modifications. A 
copy of the CTCAE version 4.0 can be downloaded from the CTEP website:
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
6.1
Dosing Delays/Omission/Modifications
Dosing interruptions are permitted in the case of medical / surgical events or logistical reasons not 
related to study therapy (e.g., elective surgery, unrelated medical events, patient vacation, and/or 
holidays). Participants held for these reasons require prior approval from the PI and should resume 
therapy within 6 weeks of the scheduled interruption. The reason for interruption should be 
documented in the participant's study record.
In the absence of an unacceptable therapy-related toxicity and/or clinical signs of disease 
progression, subjects may continue treatment at the discretion of the investigator. Subjects must 
be instructed to notify their physician immediately for any and all toxicities.
Guidelines for the management of AEs (ie, dose interruptions and dose reductions) are presented 
in the next sections. For management of AEs which can be clearly attributed to chemotherapy (i.e. 
carboplatin, nab-paclitaxel) or nivolumab, independent dose modification for either agent is 
allowed. For AEs without clear attribution to either study treatment, management of toxicity 
should include dose modifications of both agents.
Each dose reduction of carboplatin should be to one dose level lower than the current dose (see 
Table below). Dose reductions of more than one dose level are acceptable if agreed to by the 
Investigator. Once a dose level reduction has been made, dose re-escalation of carboplatin is not 
allowed in subsequent treatment cycles. In subjects unable to tolerate carboplatin at a dose of AUC 
4 mg/ml*min, carboplatin should be discontinued permanently.
Starting Dose of Carboplatin
AUC 6 mg/mL*min
First Dose Level Reduction
AUC 5 mg/mL*min
Second Dose Level Reduction
AUC 4 mg/mL*min
In the Crossover phase, each dose reduction of nab-paclitaxel should be to one dose level lower 
than the current dose (see Table below). Dose reductions of more than one dose level are 
acceptable if agreed to by the Investigator. Once a dose level reduction has been made, dose re-
escalation of nab-paclitaxel is not allowed in subsequent treatment cycles. In subjects unable to 
tolerate nab-paclitaxel at a dose of 50 mg/m2, nab-paclitaxel should be discontinued permanently.
Starting Dose of nab-paclitaxel
100 mg/m2
First Dose Level Reduction
75 mg/m2
Second Dose Level Reduction
50 mg/m2
There are no dose reductions for nivolumab. 

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Nivolumab should be held (delayed) or omitted for toxicities that are considered possibly, probably 
or definitely related to nivolumab. Carboplatin should be held (delayed) or omitted for toxicities 
that are considered possibly, probably or definitely related to carboplatin. Nab-paclitaxel should 
be held (delayed) or omitted for toxicities that are considered possibly, probably or definitely 
related to nab-paclitaxel.

If a subject receiving combination therapy (Arm A: carboplatin plus nivolumab; Arm B 
Crossover phase: nab-paclitaxel plus nivolumab) does not meet criteria for treatment 
(Section 5.2) due to a toxicity that is considered attributable to only one of the drugs of the 
combination (e.g., platelets 60,000/mm3 attributed to carboplatin), the drug causing the 
toxicity should be held, and the second drug may be administered (unless specified below 
in the corresponding AE table of the second drug).

There must be a minimum of 21 days ± 4 days between administration of each dose of 
carboplatin and, for patients in Arm A, between administration of each dose of nivolumab. 
For patients in Arm B who elect to crossover to nab-paclitaxel plus nivolumab, there must 
be a minimum of 7 days ± 1 day between administration of each dose of nab-paclitaxel and 
a minimum of 28 days ± 4 days between administration of each dose of nivolumab during 
the Crossover phase.

If treatment with chemotherapy (i.e. carboplatin or nab-paclitaxel) is held or omitted due 
to an AE and the patient cannot be retreated with chemotherapy within 6 weeks from the 
last dose, carboplatin or nab-paclitaxel should be permanently discontinued. Nivolumab 
can be continued per protocol (if the AE is unrelated).

If treatment with nivolumab is held or omitted due to an AE and the patient cannot be 
retreated with nivolumab within 9 weeks from the last dose, nivolumab should be 
permanently discontinued. Carboplatin or nab-paclitaxel can be continued per protocol (if 
the AE is unrelated).
Recommendations for treating the expected toxicities of nivolumab are provided below. 
Consultation with a medical or surgical specialist, especially prior to an invasive diagnostic or 
therapeutic procedure, is recommended.
Doses of nivolumab should be omitted (not delayed) for the following treatment-related 
toxicities: 
Grade 3 skin, drug-related adverse event
Grade 2 pneumonitis
Grade 2 and 3 serum creatinine increase (>1.5 – 6.0 x ULN)
Grade 2 or 3 neurologic signs or symptoms
Elevated AST or ALT (>3.0 – 5.0 x ULN; except in patients with 
documented liver metastases at baseline in which case AST or ALT > 5.0 – 
8.0 x ULN)

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Elevated total bilirubin  (>1.5 – 3.0 x ULN; except in patients with 
documented Gilbert´s syndrome in which case total bilirubin > 2.0 – 3.0 x 
ULN)
Grade 2 diarrhea
Grade 2 or 3 hypophysitis
Grade 2 adrenal insufficiency
Any other Grade 3 adverse event (unless otherwise specified in the tables 
below), with the exception of electrolyte imbalances/abnormalities 
considered correctable within 72 hours:
First occurrence: omit dose
Recurrence of same Grade 3 AE: discontinue nivolumab 
permanently
After omitting a dose, in order to resume treatment with nivolumab, AE must have resolved to 
grade ≤ 1 or baseline value (unless otherwise specified in the tables below), with the following 
exceptions:
- Subjects may resume treatment in the presence of grade 2 fatigue
- Drug-related endocrinopathies adequately controlled with only physiologic hormone 
replacement may resume treatment
Nivolumab treatment should be permanently discontinued for the following treatment-related 
toxicities:
Any Grade 2 drug-related uveitis, eye pain or blurred vision that does not 
respond to topical therapy and does not improve to grade 1 severity within 
re-treatment period OR requires systemic treatment
Grade 4 serum creatinine increase (> 6.0 x ULN)
Grade 3 or 4 diarrhea or colitis (except if a patient has experienced a first 
occurrence of G3 diarrhea that has resolved within 14 days and the daily 
dose of prednisone is ≤ 10 mg/day)
Grade 3 or 4 pneumonitis
Elevated AST or ALT (> 5.0 x ULN; > 8.0 x ULN for patients with 
documented liver metastases at baseline)
Grade 3 or 4 elevated total bilirubin (> 3.0 x ULN)
Grade 3 or 4 hypophysitis
Grade 3 or 4 adrenal insufficiency
Grade 4 hyperglycemia (related to study drug)
Grade 4 skin-related AE

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Any Grade symptomatic elevation of amylase and/or lipase
Immune-mediated encephalitis
Grade 3 or 4 nivolumab infusion-related reaction
Recurrent Grade 3 event (unless otherwise specified in tables below)
Any severe or Grade 3 immune-mediated adverse reaction that recurs on 
reintroduction of nivolumab, or an inability to reduce corticosteroid dose to 
10 mg or less of prednisone or equivalent per day within 12 weeks
Any Grade 4 drug-related adverse event or laboratory abnormality, except 
for the following events which do not require discontinuation:
Asymptomatic Grade 4 hematologic adverse events considered 
unrelated to nivolumab
Any adverse event, laboratory abnormality, or intercurrent illness which, in 
the judgment of the Investigator, presents a substantial clinical risk to the 
subject with continued nivolumab dosing.
6.2
Management of Toxicities Attributable to Nivolumab 
Immunosuppressive agents and the use of systemic corticosteroids are permitted in the context of 
treating adverse events. Subjects receiving corticosteroids for treatment of drug-related adverse 
events must be at  ≤ 10 mg/day prednisone or equivalent prior to re-initiation of study therapy.
6.2.1
Gastrointestinal Disorders: Diarrhea/Colitis
Subjects should be instructed to notify their physician immediately at the first signs of poorly 
formed or loose stool or an increased frequency of bowel movements as nivolumab can be 
associated with severe diarrhea/colitis. General supportive measures should be implemented 
including continuous oral hydration, correction of fluid and electrolyte abnormalities, small 
frequent meals, and stopping lactose-containing products, high fat meals, and alcohol.
 
Causes of gastrointestinal AE that are unrelated to study treatment (either carboplatin or 
nivolumab) should be ruled out. Participants experiencing intolerable grade 2 or grade 3 diarrhea 
unable to be managed with standard antidiarrheal treatments should consult a gastrointestinal (GI) 
doctor  for potential endoscopy and biopsy to help confirm immune-mediated toxicity. If a cause 
that is unrelated to study treatment (either carboplatin/nab-paclitaxel or nivolumab) is identified, 
treat accordingly and continue nivolumab therapy. Opiates/narcotics may mask symptoms of 
perforation. Infliximab should not be used in cases of perforation or sepsis.
Treatment may be restarted following the resolution of colitis. In addition, if the patient is being 
managed with corticosteroids, treatment should not be restarted until the steroids have been 
tapered down to a prednisone dose ≤ 10 mg/day. Patients with grade 3 or 4 diarrhea should 
discontinue nivolumab with the following exception: if a patient has experienced a first 
occurrence of G3 diarrhea that has resolved within 14 days and the daily dose of prednisone is 

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currently ≤ 10 mg/day, nivolumab can be resumed per protocol. Patients who resume treatment 
should be monitored closely for signs of renewed diarrhea.
Table 4: Diarrhea and Colitis Management Algorithm
Grade of Diarrhea/Colitis
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nivolumab per protocol
• Symptomatic treatment: start anti-
diarrheal agent (e.g., Imodium®) – up to 
3 agents are permitted
• Close monitoring for worsening 
symptoms
• Educate subjects to report worsening 
immediately
If worsening:
• Treat as Grade 2 or 3/4
Grade 2
• Omit nivolumab per protocol
• Symptomatic treatment: start anti-
diarrheal agent (e.g., Imodium®) – up to 
3 agents are permitted
If improved to Grade 1:
• Resume nivolumab per protocol
If persists > 5-7 days or recurs:
• 0.5-1.0 mg/kg/day 
methylprenisolone or oral equivalent
• Consider GI consult and lower 
endoscopy
• When symptoms improve to Grade 
1, taper steroids over at least 1 month, 
consider prophylactic antibiotics for 
opportunistic infections, and resume 
nivolumab when corticosteroids have 
been reduced to the equivalent of 
prednisone ≤ 10 mg/day.
If worsens or persists > 5 days with 
oral steroids:
• Treat as Grade 3 or 4
Grade 3-4
• Discontinue nivolumab per protocol*
• 1.0-2.0 mg/kg/day methylprednisolone 
IV or equivalent
• Add prophylactic antibiotics for 
opportunistic infections
• Consider GI consult and lower 
endoscopy
If improves:
• Continue steroids until Grade 1, then 
taper over at least 1 month
If persists > 3-5 days or recurs after 
improvement:
• Add infliximab 5 mg/kg (if no 
contraindication)
Note: infliximab should not be used in 
cases of perforation or sepsis

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ADL = activities of daily living; h = hour(s); IV = intravenous; NCI-CTCAE v4 = National Cancer Institute Common 
Terminology Criteria version 4.
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start of 
tapering or earlier, once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids 
should be taken into account when switching to the equivalent dose of oral corticosteroids.
*If a patient has experienced a first occurrence of G3 diarrhea that has resolved within 14 days and the daily dose of 
prednisone is currently ≤ 10 mg/day, nivolumab can be resumed per protocol
6.2.2
Pulmonary Adverse Event Management
Dyspnea, cough, fatigue, hypoxia, pneumonitis, and pulmonary infiltrates have been associated 
with the administration of nivolumab and have primarily been observed in patients with 
underlying NSCLC.
Mild-to-moderate events of pneumonitis have been reported with nivolumab.  All pulmonary 
events should be thoroughly evaluated for other commonly reported etiologies such as 
pneumonia/infection, lymphangitic carcinomatosis, pulmonary embolism, heart failure, chronic 
obstructive pulmonary disease (COPD), or pulmonary hypertension and the following should be 
performed:

Measurement of oxygen saturation (i.e., arterial blood gas)

High-resolution CT scan of the chest

Bronchoscopy with bronchoalveolar lavage and biopsy

Pulmonary function tests (with diffusion capacity of the lung for carbon monoxide [DLCO])
Patients will be assessed for pulmonary signs and symptoms throughout the study. Patients will 
also have CT scans of the chest at every tumor assessment (see Section 11). If the cause of a 
pulmonary AE is considered to be unrelated to study treatment, treat accordingly and continue 
nivolumab therapy. Evaluate with imaging and pulmonary consultation.
Table 5. Management of Pulmonary Adverse Event
Grade of Pneumonitis
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Dose of nivolumab may be held for 
further evaluation per investigator 
discretion
• Monitor for symptoms every 2-3 days 
• Consider Pulmonary and ID consults
• Re-image at least every 3 weeks
If worsening:
• Treat as Grade 2 or 3/4
Grade 2
• Omit dose of nivolumab per protocol
• Pulmonary and ID consults
• Monitor symptoms daily, consider 
hospitalization 
• Re-image at least every 1-3 days
If improves:
• When symptoms return to near 
baseline, taper steroids over at least 1 
month and then resume nivolumab 

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• 1.0 to 2.0 mg/kg/day 
methylprednisolone IV or oral equivalent 
• Consider bronchoscopy, lung biopsy
per protocol and consider 
prophylactic antibiotics
If not improving after 2 weeks or 
worsening:
• Treat as Grade 3/4 (discontinue 
nivolumab unless an alternative 
etiology of findings is identified)
Grade 3-4
• Discontinue nivolumab per protocol
• Hospitalize
• Pulmonary and ID consults
• 2.0-4.0 mg/kg/day methylprednisolone 
IV or IV equivalent
• Add prophylactic antibiotics for 
opportunistic infections
• Consider bronchoscopy, lung biopsy
If improves to baseline:
• Taper steroids over at least 6 weeks
If not improving after 48 hours or 
worsening: 
• Add additional immunosuppression 
(e.g. infliximab, cyclophosphamide, 
IVIG or mycophenolate mofetil)
ID = infectious disease; IV = intravenous; IVIG = intravenous immunoglobulin; NCI-CTCAE v4 = National Cancer 
Institute Common Terminology Criteria version 4; ULN = upper limit of normal.
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start
of tapering or earlier, once sustained clinical improvement is observed. Lower biovailabity of oral corticosteroids
should be taken into account when switching to the equivalent dose of oral corticosteroids.
6.2.3
Hepatobiliary Disorders
Elevations of ALT, AST, and bilirubin have been observed during treatment with nivolumab. It is 
recommended that participants with elevation of ALT, AST, and/or bilirubin have more frequent 
laboratory monitoring of these parameters. If possible, hepatotoxic concomitant medications 
should be discontinued in participants who develop increased values of ALT, AST, or bilirubin. 
Causes of hepatobiliary disorders that are unrelated to study treatment (either carboplatin or 
nivolumab) should be ruled out. If a cause that is unrelated to treatment is identified, treat 
accordingly and continue nivolumab therapy. Consider imaging to rule out obstruction.
Table 6. Hepatic Adverse Event Management Algorithm
Grade of Elevated AST, ALT or 
Bilirubin
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nivolumab per protocol
• Continue LFT monitoring protocol 
every 7-10 days for at least 4 weeks a
If worsening:
• Treat as Grade 2 or 3/4

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Grade 2
• Omit nivolumab per protocol with the 
following exceptions:
a) Documented liver metastases and 
baseline AST or ALT > 3.0 to ≤ 5.0 x 
ULN
b) Documented Gilbert´s syndrome and 
total bilirubin > 1.5 to ≤ 2.0 x ULN
• Increase frequency of LFT monitoring 
to every 3-5 days a
• Consider referral to a hepatologist
If returns to baseline:
• Resume routine monitoring, resume 
nivolumab per protocol
If elevations persist > 5-7 days or 
worsen:
• 0.5-1.0 mg/kg/day 
methylprednisolone or oral 
equivalent and when LFT returns to 
Grade 1 or baseline, taper steroids 
over at least 1 month, consider 
prophylactic antibiotics for 
opportunistic infections, and resume 
nivolumab per protocol
Grade 3-4
• Discontinue nivolumab b
• Increase frequency of monitoring to 
every 1-2 days
• Consider referral to hepatologist and 
liver biopsy to establish etiology of 
hepatic injury
• 1.0-2.0 mg/kg/day methylprednisolone 
IV or IV equivalent c
• Add prophylactic antibiotics for 
opportunistic infections
If returns to Grade 2:
• Taper steroids over at least 1 month
If does not improve in > 3-5 days, or 
worsens or rebounds: 
• Add mycophenolate mofetil 1g BID
• If no response within an additional 
3-5 days, consider other 
immunosuppressants per local 
guidelines
ALT = alanine aminotransferase; AST = aspartate aminotransferase; IV = intravenous; LFT = liver function test; 
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4; ULN = upper limit of 
normal.
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start
of tapering or earlier, once sustained clinical improvement is observed. Lower biovailabity of oral corticosteroids
should be taken into account when switching to the equivalent dose of oral corticosteroids.
a LFT monitoring does not to be increased in patients with documented liver metastases and baseline AST or ALT > 
3.0 to ≤ 5.0 x ULN or patients with documented Gilbert´s syndrome and total bilirubin > 1.5 to ≤ 2.0 x ULN.
b Nivolumab therapy may be omitted rather than permanently discontinued if AST/ALT > 5.0 to ≤ 8.0 x ULN and 
patient has documented liver metastases at baseline. 
c The recommended starting dose for Grade 4 hepatitis is 2 mg/kg/day methylprednisolone IV.
6.2.4
Elevated Amylase and/or Lipase 
Patients may develop symptomatic and/or radiographic evidence of pancreatitis or pancreatic 
dysfunction. Amylase and lipase should be checked if there is clinical suspicion for pancreatitis. 
Causes of pancreatitis that are unrelated to study treatment (e.g. gallstones, alcohol consumption, 
infections) should be ruled out. If a cause that is unrelated to treatment is identified, treat 

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accordingly and continue nivolumab therapy. Corticosteroids do not seem to alter the natural 
history of lipase/amylase elevations. Patients with symptomatic or radiographic pancreatitis 
suspected to be nivolumab-related should discontinue nivolumab and consider consulting a 
gastroenterologist for management.
Table 7. Management of Elevated Amylase and/or Lipase
Grade of Elevated Amylase and/ 
or Lipase (NCI-CTCAE v4)
Management
Follow-up
Any grade
• Patients with symptomatic (e.g. abdominal 
pain, hyperglycemia) or radiographic 
pancreatitis considered to be nivolumab-
related should discontinue nivolumab
• Consider GI consultation
• Elevations should be monitored 
approximately every 7-10 days until ≤ 
Grade 1
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4.
6.2.5
Endocrinopathy Management
Changes in thyroid function tests (TFTs) and hypothyroidism have been reported with 
nivolumab. Non-inflammatory causes should be ruled out. If a non-inflammatory cause is 
identified, treat accordingly and continue nivolumab therapy. Management of thyroid 
dysfunction (e.g., symptomatic hypothyroidism) should follow accepted clinical practice 
guidelines. Nivolumab does not need to be held for asymptomatic participants. Visual field 
testing, endocrinology consultation, and imaging should be considered.
Note: all patients with symptomatic pituitary enlargement, regardless of hormone deficiency, 
including severe headache or enlarged pituitary on MRI or aseptic meningitis or encephalitis, 
should be considered grade 3 events.  Isolated thyroid or testosterone deficiency may be treated 
as grade 2 if there are no other associated deficiencies and adrenal function is monitored.
Table 8. Endocrinopathy Management Algorithm
Grade of Endocrinopathy 
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nivolumab per protocol
• If TSH < 0.5 x LLN, or TSH > 2.0 x 
ULN, or consistently out of range in 2 
subsequent measurements: include fT4 at 
subsequent cycles as clinically indicated. 
• Consider endocrinology consult.
-
Grade 2 a
• Evaluate endocrine function
• Consider pituitary scan
If symptomatic with abnormal lab and/or 
pituitary scan: b
If improves with or without hormone 
replacement:
• Taper steroids over at least 1 month 
and consider prophylactic antibiotics 

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• Delay/omit nivolumab per protocol c
• 1-2 mg/kg/day methylprednisolone IV 
or PO equivalent
• Initiate appropriate hormone therapy
No abnormal lab/pituitary MRI scan but 
symptoms persist:
• Repeat labs in 1-3 weeks / MRI in 1 
month
for opportunistic infections and 
resume nivolumab per protocol
• Subjects with adrenal insufficiency 
may need to continue steroids with 
mineralocorticoid component
Grade 3
Includes suspicion of adrenal crisis 
(e.g. severe dehydration, 
hypotension, shock out proportion 
to current illness)
• Omit nivolumab per protocol
• Consult endocrinologist
• 1-2 mg/kg/day methylprednisolone IV 
or IV equivalent
If suspicion of adrenal crisis:
• Rule out sepsis
• Stress dose of IV steroids with 
mineralocorticoid activity
• IV fluids
If Grade 3 hypophysitis or adrenal 
insufficiency is confirmed:
• Discontinue nivolumab permanently
If improves with or without hormone 
replacement to ≤ Grade 1:
• Taper steroids over at least 1 month 
and consider prophylactic antibiotics 
for opportunistic infections and 
resume nivolumab per protocol
Grade 4
• Discontinue nivolumab per protocol
• Consult endocrinologist
• 1-2 mg/kg/day methylprednisolone IV 
or IV equivalent
If suspicion of adrenal crisis:
• Rule out sepsis
• Stress dose of IV steroids with 
mineralocorticoid activity
• IV fluids
If improves with or without hormone 
replacement to ≤ Grade 1:
• Taper steroids over at least 1 month 
and consider prophylactic antibiotics 
for opportunistic infections
TSH = thyroid stimulating hormone; fT4 = free thyroxine; IV = intravenous; PO = oral administration; ULN = upper 
limit of normal; LLN = lower limits of normal; MRI = magnetic resonance imaging; NCI-CTCAE v4 = National 
Cancer Institute Common  Terminology Criteria version 4
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start of 
tapering or earlier, once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids 
should be taken into account when switching to the equivalent dose of oral corticosteroids.
a Excludes Grade 2 hypo- or hyperthyroidism. These patients should be treated with hormone replacement therapy; no 
dose modifications of nivolumab unless worsening to Grade 3 or 4.
b Patients must be evaluated to rule out pituitary disease prior to initiating thyroid replacement and steroids, including 
baseline serum: cortisol, ACTH, TSH and free T4.

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c Nivolumab therapy should be omitted, rather than delayed, if Grade 2 hypophysitis or adrenal insufficiency.
6.2.6
Dermatologic Adverse Event Management
Treatment-emergent rash has been associated with nivolumab. The majority of cases of rash were 
mild in severity and self-limited, with or without pruritus. A dermatologist should evaluate 
persistent and/or severe rash or pruritus.  Causes of dermatologic AE that are unrelated to study 
treatment (either carboplatin or nivolumab) should be ruled out. A biopsy should be performed 
unless contraindicated.
If a cause that is unrelated to treatment is identified, treat accordingly and continue nivolumab 
therapy. Low-grade immune-related rash and pruritus have been treated with symptomatic therapy 
(e.g., antihistamines). Pruritus may occur with or without skin rash and should be treated 
symptomatically. Topical or parenteral corticosteroids may be required for more severe symptoms. 
Skin rash typically occurs early and may be followed by additional events particularly during 
steroid taper.
Table 9: Dermatologic Adverse Event Management Algorithm
Grade of Dermatologic Adverse 
Event (NCI-CTCAE v4)
Management
Follow-up
Grade 1-2 
• Continue nivolumab per protocol
• Symptomatic therapy (e.g. 
antihistamines, topical steroids)
If persists > 1-2 weeks or recurs:
• Consider skin biopsy
• Interrupt nivolumab therapy per 
protocol
• Consider 0.5-1.0 mg/kg/day 
methylprednisone IV or oral 
equivalent. Once improving, taper 
steroids over at least 1 month, 
consider prophylactic antibiotics for 
opportunistic infections, and resume 
nivolumab therapy per protocol
If worsens:
• Treat as Grade 3-4
Grade 3-4 
• Omit (if grade 3) or discontinue (if 
grade 4) nivolumab therapy per protocol
• Consider skin biopsy
• Dermatology consult
• 1.0-2.0 mg/kg/day IV methylprednisone 
IV or IV equivalent
If improves to grade 1:
• Taper steroids over at least 1 
month and add prophylactic 
antibiotics for opportunistic 
infections
• Resume nivolumab per protocol

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BSA = body surface area; IV = intravenous. NCI-CTCAE v4 = National Cancer Institute Common  Terminology 
Criteria version 4
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start 
of tapering or earlier, once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids 
should be taken into account when switching to the equivalent dose of oral corticosteroids.
6.2.7
Renal Adverse Event Management 
Causes of renal AE that are unrelated to study treatment (either carboplatin or nivolumab) should 
be ruled out. If a cause that is unrelated to treatment is identified, treat accordingly and continue 
nivolumab therapy.
Table 10. Renal Adverse Event Management Algorithm
Grade of Creatinine Elevation 
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nivolumab per protocol
• Routine creatinine monitoring per 
protocol
Grade 2-3
• Omit nivolumab per protocol 
• Monitor creatinine weekly
• Consider nephrologist consult and renal 
biopsy
• 0.5-1.0 mg/kg/day prednisone IV or PO 
equivalent if considered nivolumab-
related
If improves to ≤ Grade 1:
• Taper steroids over at least 1 
month, consider prophylactic 
antibiotics for opportunistic 
infections, and resume nivolumab 
therapy per protocol and routine 
creatinine monitoring per protocol
If elevations persist > 7 days or 
worsen: 
• Treat as Grade 4
Grade 4
• Discontinue nivolumab
• Monitor creatinine daily
• Consult nephrologist and consider renal 
biopsy
• 1.0-2.0 mg/kg/day methylprednisolone 
IV or IV equivalent if considered 
nivolumab-related
If improves to ≤ Grade 1:
• Taper steroids over at least 1 month 
and add prophylactic antibiotics for 
opportunistic infections
ADL = activities of daily living; IV = intravenous; PO = oral administration; NCI-CTCAE v4 = National Cancer 
Institute Common Terminology Criteria version 4; ULN = upper limit of normal.
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start of 
tapering or earlier, once sustained clinical improvement is observed. Lower bioavailability of oral
corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.

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6.2.8
Hematologic Adverse Event Management
Hematologic AE (e.g., anemia, neutropenia, febrile neutropenia, thrombocytopenia) related to 
nivolumab are rare. Non-inflammatory causes of hematologic AE should be ruled out, 
particularly related to carboplatin. If a non-inflammatory cause is identified, treat accordingly 
and continue nivolumab therapy unless otherwise specified in the table below. Consider 
peripheral blood smear and hematology consultation.
 
Table 11. Hematologic Adverse Event Management Algorithm
Grade of Hematologic Adverse 
Event
(NCI-CTCAE v4)
Management
Follow-up
Grade ≤ 3
• Continue nivolumab per protocol
• Supportive care per local guidelines
If Grade 3 hematologic AE recurr despite 
two dose level reductions of carboplatin:
• Consider hematology consult, antibody 
panel and bone marrow biopsy a
• 0.5-1.0 mg/kg/day prednisone IV or PO 
equivalent if considered nivolumab-
related
If improves to ≤ Grade 2: 
• Taper steroids over at least 1 month 
and add prophylactic antibiotics for 
opportunistic infections
Grade 4
• Delay/omit nivolumab until resolves to 
≤ Grade 2
• Supportive care per local guidelines
If Grade 4 hematologic AE recurr despite 
two dose level reductions of carboplatin:
• Consider hematology consult, antibody 
panel and bone marrow biopsy a
• 1.0-2.0 mg/kg/day prednisone IV or PO 
equivalent if considered nivolumab-
related and permanently discontinue 
nivolumab. 
If improves to ≤ Grade 2: 
• Taper steroids over at least 1 
month, resume nivolumab per 
protocol and add prophylactic 
antibiotics for opportunistic 
infections
If symptomatic or Grade 4 persists 
despite steroids > 14 days:
• Consider IVIG or other 
immunosuppressive therapies per 
local guidelines 
• Discontinue nivolumab if 
considered nivolumab-related
Febrile neutropenia
• Hold nivolumab until resolved (ANC ≥  
1000/mm3, fever < 38ºC)
• Supportive care per local guidelines
 
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4; PO = oral administration; IV 
= intravenous; IVIG = intravenous immunoglobulin.

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Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start 
of tapering or earlier, once sustained clinical improvement is observed. Lower bioavailability of oral
corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.
a If immune-mediated hemolytic anemia or thrombocytopenia are suspected, Coombs test, anti-platelet antibodies, 
peripheral blood smear and/or bone marrow aspiration or biopsy should be considered.
6.2.9
Neurologic Adverse Event Management 
Causes of neurologic AE that are unrelated to treatment (either carboplatin or nivolumab) should 
be ruled out. If a cause that is unrelated to treatment is identified, treat accordingly and continue 
nivolumab therapy. Consider visual field testing, endocrinology consultation, and imaging.
Patients that experience nivolumab-related aseptic meningitis, encephalitis, myopathy, peripheral 
demyelinating neuropathy, cranial neuropathy (other than peripheral n. VII), Guillain-Barre 
syndrome, and myasthenia gravis should discontinue nivolumab therapy.
Table 12. Neurologic Adverse Event Management Algorithm
Grade of Neurologic Adverse Event
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nivolumab per protocol
• Continue to monitor the patient
If worsening:
• Treat as Grade 3/4
Grade 2-3
• Omit nivolumab per protocol 
• Treat symptoms per local guidelines
• Consider 0.5-1.0 mg/kg/day prednisone 
IV or PO equivalent if considered 
nivolumab-related
If improves to baseline:
• Taper steroids over at least 1 month, 
consider prophylactic antibiotics for 
opportunistic infections and resume 
nivolumab therapy per protocol 
Grade 4
• Discontinue nivolumab
• Obtain neurology consult
• Treat symptoms per local guidelines
• 1.0-2.0 mg/kg/day methylprednisolone 
IV or IV equivalent 
• Add prophylactic antibiotics for 
opportunistic infections
If improves to Grade 2:
• Taper steroids over at least 1 month
If worsens or atypical presentation: 
• Consider IVIG or other 
immunosuppressive therapies per 
local guidelines
ADL= activities of daily living; NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 
4; PO = oral administration; IV = intravenous; IVIG = intravenous immunoglobulin; 
Note: Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (eg, prednisone) at start 
of tapering or earlier, once sustained clinical improvement is observed. Lower bioavailability of oral
corticosteroids should be taken into account when switching to the equivalent dose of oral corticosteroids.

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6.2.10 Nivolumab Infusion-Related Reactions
Nivolumab contains only human immunoglobulin protein sequences and, therefore, 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 within 24 hours to the study PI and reported as a SAE if criteria are met. 
Infusion reactions should be graded according to National Cancer Institute Common Terminology 
Criteria for Adverse Events (NCI CTCAE version 4.0) guidelines. Treatment recommendations 
are provided below and may be modified based on local treatment standards and guidelines as 
appropriate: 
Table 13: Management of Nivolumab Infusion-Related Reactions
Grade of Nivolumab Infusion-
Related Reaction (NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nivolumab per protocol. 
Remain at beside.
• Institute prophylactic medications 
with subsequent infusions
Grade 2
• Hold nivolumab until resolution to ≤ 
Grade 1
• Refer to management and 
rechallenging instructions below
Grade 3-4
• Discontinue nivolumab therapy
NCI-CTCAE v4 = National Cancer Institute Common  Terminology Criteria version 4
For 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.
For 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. Restart the infusion at 50% of the 

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original infusion rate when symptoms resolve to Grade ≤ 1; if no further complications ensue after 
30 minutes, the rate may be increased to 100% of the original infusion rate. Monitor participant 
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 participant 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. 
For Grade 3 or Grade 4 symptoms: 
Grade 3: prolonged [e.g. not rapidly responsive to symptomatic medication and/or brief 
interruption of infusion]; recurrence of symptoms following initial improvement; hospitalization 
indicated for other clinical sequelae [e.g. renal impairment, pulmonary infiltrates).
Grade 4: life-threatening; pressor or ventilatory support indicated.
Immediately discontinue infusion of nivolumab. Begin an IV infusion of normal saline, treat with 
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. 
Participant should be monitored until the investigator is comfortable that the symptoms will not 
recur. 
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 (e.g., appearance of a localized or generalized pruritis within 1 week 
after treatment), symptomatic treatment may be given (e.g., oral antihistamine, or corticosteroids).
6.3
Management of Toxicities Attributable to Carboplatin
6.3.1
Hematological Adverse Event Management
Hematological toxicities (ie, neutropenia and thrombocytopenia) and associated complications 
have been observed with carboplatin and may be managed with dose delays and/or dose reductions. 
Use of granulocyte colony-stimulating factor support for neutrophil recovery is allowed per 
investigator discretion and in accordance with accepted guidelines after the first incidence of 
clinically relevant cytopenia.
Complete blood counts with differentials and platelets should be performed regularly. Participants 
with hematological toxicities may require additional or more frequent laboratory tests according 
to institutional guidelines. Febrile neutropenia or evidence of infection associated with neutropenia 
must be assessed immediately and treated appropriately and in a timely manner according to 
institutional guidelines.

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Dose reductions or dose interruptions for anemia are not mandated but can be applied as clinically 
indicated. Supportive care (i.e. red blood cell transfusions) may be managed according to 
institutional guidelines.
Table 14. Hematological Adverse Event Management Algorithm
Grade of Hematological Adverse 
Event (NCI-CTCAE v4)
Management
Follow-up
NEUTROPENIA
Grade 1-2
• Continue carboplatin at same dose
Grade 3-4
• Hold carboplatin until ANC ≥ 1000/mm3
First occurrence:
• Resume carboplatin with a dose reduction 
by 1 dose level (-1 AUC) for all subsequent 
cycles (unless initiating G-CSF)
Second occurrence:
• Resume carboplatin with another dose 
reduction by 1 dose level (-2 AUC) for all 
subsequent cycles (unless initiating G-CSF)
• G-CSF may be used between 
days 2-6 at physician discretion, 
and to avoid dose reduction
• If Grade 3-4 toxicity persists 
despite 2 dose level reductions, 
discontinue carboplatin
FEBRILE NEUTROPENIA
ANC < 1000/mm3 with a single 
temperature > 38.3ºC (101ºF) or a 
sustained temperatuire of ≥ 38ºC 
(100.4ºF) for > 1 hour
• Hold carboplatin until resolved (ANC ≥  
1000/mm3, fever < 38ºC)
First occurrence:
• Resume carboplatin with a dose reduction 
by 1 dose level (AUC 5) for all subsequent 
cycles (unless initiating G-CSF)
Second occurrence:
• Resume carboplatin with another dose 
reduction by 1 dose level (AUC 4) for all 
subsequent cycles (unless initiating G-CSF)
• G-CSF may be used between 
days 2-6 at physician discretion, 
and to avoid dose reduction
• If febrile neutropenia despite 2 
dose level reductions, discontinue 
carboplatin
THROMBOCYTOPENIA
≥ 75,000/mm3
• No change to carboplatin
50,000 - 75,000/mm3
First occurrence: 
• Hold carboplatin until recovery to 
75,000/mm3
• Resume carboplatin with a 1 dose level 
reduction (AUC 5) for all subsequent cycles
• Supportive platelet transfusion 
and/or romiplostim may be used to 
meet criteria for treatment

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Second occurrence:
• Hold carboplatin until recovery to 
75,000/mm3
• Resume carboplatin with another dose 
reduction by 1 dose level (AUC 4) for all 
subsequent cycles*
< 50,000/mm3
First occurrence (of any thrombocytopenia 
<75,000): 
• Hold carboplatin until recovery to 
75,000/mm3
• Resume carboplatin with a 1 dose level 
reduction (AUC 5) for all subsequent cycles
Second occurrence (of any 
thrombocytopenia <75,000):
• Hold carboplatin until recovery to 
75,000/mm3
• Resume carboplatin with another dose 
reduction by 1 dose level (AUC 4) for all 
subsequent cycles*
• Supportive platelet transfusion 
and/or romiplostim may be used to 
meet criteria for treatment
• If Grade 3-4 toxicity persists 
despite 2 dose level reductions, 
discontinue carboplatin
ANEMIA
All grades
• For all anemia events related to 
carboplatin, regardless of grade, iron studies 
should be checked and iron should be 
replaced as indicated.
• Red blood cell transfusions can 
be given at the investigator´s 
discretion as needed for symptom 
control.
*If held at AUC4, restarting carboplatin at the same dose is per investigator discretion. Carboplatin 
should be discontinued after three mandated dose holds at this dose level, unless approval is 
granted from the study sponsor. 
6.3.2
Nausea and Vomiting Adverse Event Management
Carboplatin has moderate to high emetic potential, although manageable with adequate anti-emetic 
therapy. Prophylactic anti-emetic therapy (e.g., aprepitant, ondansetron, palonosteron, etc.) should 
be administered to all patients and specific agents are at the discretion of the treating physician.

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Table 15. Nausea and Vomiting Adverse Event Management Algorithm
Grade of Nausea and/or Vomiting 
Adverse Event (NCI-CTCAE v4)
Management
Follow-up
Grade 1-2 
• Continue carboplatin at same dose
• Nausea and/or vomiting should be 
controlled with adequate anti-emetic 
therapy. 
• Patients are encouraged to take plenty of 
oral fluids
• Prophylactic anti-emetic therapy 
should be administered to all patients; 
specific agents are at the discretion of 
the treating physician (please see 
recommended regimens below)
Grade 3-4
• Hold carboplatin until resolved to ≤ 
Grade 1
• Resume carboplatin at previous 
administered dose with modification of 
premedications.
• Persistent toxicity ≥ Grade 3 despite 
maximal supportive care, dose reduce 
carboplatin by one dose level (AUC 5) 
at the next chemotherapy cycle for all 
subsequent cycles
NCI-CTCAE v4 = National Cancer Institute Common  Terminology Criteria version 4
Recommended prophylactic anti-emetic therapy includes:
-Aprepitant 125 mg oral (1 capsule on the same day, to be administered approximately 60 minutes 
prior to carboplatin)
-Aprepitant 80 mg oral (1 capsule daily for 2 days, starting 24 hours after the administration of 
carboplatin)
-Palonosetron 0.25 mg IV (1 dose to be administered 30 minutes prior to carboplatin)
-Lorazepam 0.5-1.0 mg oral (every 4-6 hours if needed for anticipatory nausea or vomiting, or 
anxiety)
-Dexamethasone: Corticosteroids should be avoided unless deemed necessary to control refractory 
nausea or vomiting. If needed, administer 4 mg oral (at the start of treatment) or 4mg IV (dose to 
be administered 30 minutes prior to carboplatin)
6.3.3
Renal Adverse Event Management
Table 16. Renal Adverse Event Management Algorithm
Serum Creatinine Elevation or 
Abnormal Creatinine Clearance
Management
Follow-up
Creatinine > ULN to ≤ 1.5 x ULN or 
CrCL ≥ 45 ml/min
• Continue carboplatin at same dose
• Patients are encouraged to take 
plenty of oral fluids
Creatinine > 1.5 to ≤ 2.0 x ULN 
or CrCL ≥ 30 to < 45 ml/min
• Reduce carboplatin one dose level (-1 
AUC) for all subsequent cycles
• Patients are encouraged to take 
plenty of oral fluids

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Creatinine > 2.0 to ≤ 6.0 x ULN 
or CrCL ≥ 10 to < 30 ml/min
• Hold carboplatin until ≤ 2.0 x ULN or 
CrCL ≥ 30 ml/min.
• Reduce carboplatin one dose level (-1 
AUC) for all subsequent cycles
• Consider nephrologist consult
• Once resolved and carboplatin 
resumed, weekly creatinine 
monitoring is recommended
• Patients are encouraged to take 
plenty of oral fluids
Creatinine > 6.0 x ULN 
or CrCL < 10 ml/min
• Discontinue carboplatin
• Monitor creatinine daily
• Consult nephrologist
CrCL = Creatinine clearance calculated using Calvert formula; mL/min= milliliters/minute
Note: If carboplatin is already reduced to AUC 4 and the patient requires another dose level reduction, carboplatin 
therapy will be discontinued.
6.3.4
Neurologic Adverse Event Management
Table 17. Neurologic Adverse Event Management Algorithm
Grade of Sensory Neuropathy
 (NCI-CTCAE v4)
Management
Grade 1
• Continue carboplatin at same dose
Grade 2
• First occurrence: reduce carboplatin one dose level (AUC 5)
• Second occurrence: delay carboplatin until resolved to ≤ Grade 1 
and resume with another dose level reduction (AUC 4)
Grade 3-4
• Discontinue carboplatin
ADL = activities of daily living; NCI-CTCAE v4 = National Cancer Institute Common  Terminology Criteria version 
4
6.3.5
Hepatobiliary Disorders
Table 18. Hepatobiliary Adverse Event Management Algorithm
Grade of Elevated AST, ALT or 
Bilirubin
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue carboplatin at same dose
Grade 2
• Delay/omit carboplatin until it resolves 
to  ≤ Grade 1 or baseline, with the 
following exceptions:
a) Documented liver metastases and 
baseline AST or ALT > 3.0 to ≤ 5.0 x 
ULN
If returns to ≤ Grade 1 or baseline:
• Resume carboplatin at same dose

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b) Documented Gilbert´s syndrome and 
baseline total bilirubin > 1.5 to ≤ 3.0 x 
ULN
Grade 3
• Delay/omit carboplatin until it resolves 
to  ≤ Grade 1 or baseline
If returns to ≤ Grade 1 or baseline:
• Resume carboplatin at one dose level 
reduction (-1 AUC) for all subsequent 
cycles
Grade 4
• Discontinue carboplatin
ALT = alanine aminotransferase; AST = aspartate aminotransferase; LFT = liver function test; NCI-CTCAE v4 = 
National Cancer Institute Common Terminology Criteria version 4; ULN = upper limit of normal
6.3.6
Management of Carboplatin Infusion-Related Reactions and Hypersensitivity
Patients should be observed closely for hypersensitivity reactions, particularly during the first and 
second infusions. Hypersensitivity reactions may occur within a few minutes following the 
initiation of the infusion of carboplatin. If hypersensitivity reactions occur, minor symptoms such 
as flushing or localised cutaneous reactions do not require discontinuation of therapy. The infusion 
may be temporarily interrupted and when symptoms improve re-started at a slower infusion rate. 
Chlorphenamine 10mg iv may be administered. Severe reactions, such as hypotension, 
bronchospasm or generalised rash/erythema require immediate discontinuation of carboplatin and 
appropriate therapy.
Table 19. Carboplatin Infusion-Related Reactions and Hypersensitivity Management
Grade of Carboplatin Infusion-
Related Reaction (NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue carboplatin per protocol. 
Remain at beside.
• Institute prophylactic medications 
with subsequent infusions
Grade 2
• Hold carboplatin until resolution to ≤ 
Grade 1
• Refer to management and 
rechallenging instructions below
Grade 3
• For patients on carboplatin 
monotherapy, infusion should be held 
until resolution to ≤ Grade 1
• If patient is not rechallenged, 
desensitization may be considered per 
physician discretion
Grade 4
• Discontinue carboplatin therapy
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4

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For 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 
carboplatin administrations.
For 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 carboplatin 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. Restart the infusion at 50% of the 
original infusion rate when symptoms resolve to Grade ≤ 1; if no further complications ensue after 
30 minutes, the rate may be increased to 100% of the original infusion rate. Monitor participant 
closely. If symptoms recur, then no further carboplatin will be administered at that visit. 
Administer diphenhydramine 50 mg IV, and remain at bedside and monitor the participant 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 carboplatin 
administration. If necessary, corticosteroids (recommended dose: up to 25 mg of IV 
hydrocortisone or equivalent) may be used.
For Grade 3 or Grade 4 symptoms: 
Grade 3: prolonged [e.g. not rapidly responsive to symptomatic medication and/or brief 
interruption of infusion]; recurrence of symptoms following initial improvement; hospitalization 
indicated for other clinical sequelae [e.g. renal impairment, pulmonary infiltrates).
Grade 4: life-threatening; pressor or ventilatory support indicated.
Immediately discontinue infusion of carboplatin. Begin an IV infusion of normal saline, treat with 
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. 
Participant should be monitored until the investigator is comfortable that the symptoms will not 
recur. 
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 (e.g., appearance of a localized or generalized pruritis within 1 week 
after treatment), symptomatic treatment may be given (e.g., oral antihistamine, or corticosteroids). 

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Desensitization is allowed for patients on carboplatin monotherapy and may be considered per 
physician discretion. 
6.3.7
Management of All Other Adverse Events
Table 20: General Guidance for All Other Adverse Events 
Grade of Adverse Event
 (NCI-CTCAE v4)
Management
Grade 1-2
• Continue carboplatin at same dose.
Grade 3
• Delay/omit carboplatin until resolution to ≤ Grade 1 and resume 
carboplatin at one dose level reduction (AUC 5) a
Grade 4
• Discontinue carboplatin therapy
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4
a If a patient has persistent Grade 3 AE, a further dose level reduction (to AUC 4) is allowed at physician´s 
discretion.
6.4
Management of Toxicities Attributable to nab-Paclitaxel Alone
For toxicities in this section, which are attributable to nab-paclitaxel alone, concurrent holding of 
nivolumab is at the discretion of the treating physician, as described in the general guidelines at 
the start of Section 6.1. 
6.4.1
Hematological Adverse Event Management
Hematological toxicities (ie, neutropenia and thrombocytopenia) and associated complications 
have been observed with nab-paclitaxel and may be managed with dose delays and/or dose 
reductions. Use of granulocyte colony-stimulating factor support for neutrophil recovery is 
allowed per investigator discretion and in accordance with accepted guidelines after the first 
incidence of clinically relevant cytopenia.
Complete blood counts with differentials and platelets should be performed regularly. Participants 
with hematological toxicities may require additional or more frequent laboratory tests according 
to institutional guidelines. Febrile neutropenia or evidence of infection associated with neutropenia 
must be assessed immediately and treated appropriately and in a timely manner according to 
institutional guidelines.
Dose reductions or dose interruptions for anemia are not mandated but can be applied as clinically 
indicated. Supportive care (i.e. red blood cell transfusions) may be managed according to 
institutional guidelines.

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Table 21. Hematological Adverse Event Management Algorithm
Grade of Hematological Adverse 
Event (NCI-CTCAE v4)
Management
Follow-up
NEUTROPENIA
Grade 1-2
• Continue nab-paclitaxel at same dose
Grade 3-4
• Hold nab-paclitaxel until ANC ≥ 
1000/mm3. If delay of next dose by >7 days 
for nadir ANC <1000/mm3 or nadir ANC 
<500/mm3 for >7 days:
First occurrence:
• Resume nab-paclitaxel with a dose 
reduction by 1 dose level (75 mg/m2) for all 
subsequent cycles (unless initiating G-CSF)
Second occurrence:
• Resume nab-paclitaxel with another dose 
reduction by 1 dose level (50 mg/m2) for all 
subsequent cycles
Third occurrence:
• Discontinue nab-paclitaxel permanently. 
Continuation of nivolumab is at physician´s 
discretion.
• Growth factor support may be 
used at physician´s discretion, and 
to avoid dose reduction
• If Grade 3-4 toxicity persists 
despite 2 dose level reductions, 
discontinue nab-paclitaxel
FEBRILE NEUTROPENIA
ANC < 1000/mm3 with a single 
temperature > 38.3ºC (101ºF) or a 
sustained temperatuire of ≥ 38ºC 
(100.4ºF) for > 1 hour
• Hold nab-paclitaxel until resolved (ANC ≥  
1000/mm3, fever < 38ºC)
First occurrence:
• Resume nab-paclitaxel with a dose 
reduction by 1 dose level (75 mg/m2) for all 
subsequent cycles (unless initiating G-CSF)
Second occurrence:
• Resume nab-paclitaxel with another dose 
reduction by 1 dose level (50 mg/m2) for all 
subsequent cycles
Third occurrence:
• Growth factor support may be 
used at physician´s discretion, and 
to avoid dose reduction
• If febrile neutropenia despite 2 
dose level reductions, discontinue 
nab-paclitaxel

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• Discontinue nab-paclitaxel permanently. 
Continuation of nivolumab is at physician´s 
discretion.
THROMBOCYTOPENIA
≥ 75,000/mm3
• No changes to nab-paclitaxel
< 75,000/mm3
First occurrence (of any thrombocytopenia 
<75,000): 
• Hold nab-paclitaxel until recovery to 
75,000/mm3
• Resume nab-paclitaxel with 1 dose level 
(75 mg/m2) reduction for all subsequent 
doses
Second occurrence (of any 
thrombocytopenia <75,000):
• Hold nab-paclitaxel until recovery to 
75,000/mm3
• Resume nab-paclitaxel with another dose 
reduction by 1 dose level (50 mg/m2) for all 
subsequent cycles*
Third occurrence (of any thrombocytopenia 
<75,000):
• Discontinue nab-paclitaxel permanently. 
Continuation of nivolumab is at physician´s 
discretion.
• Supportive platelet transfusion 
and/or romiplostim may be used to 
meet criteria for treatment
• If Grade 3-4 toxicity persists 
despite 2 dose level reductions, 
discontinue nab-paclitaxel
ANEMIA
All grades
• For all anemia events related to nab-
paclitaxel, regardless of grade, iron studies 
should be checked and iron should be 
replaced as indicated.
• Red blood cell transfusions can 
be given at the investigator´s 
discretion as needed for symptom 
control.
*If held at 50mg/m2, restarting nab-paclitaxel at the same dose is per investigator discretion. Nab-
paclitaxel should be discontinued after three mandated dose holds at this dose level, unless 
approval is granted from the study sponsor. 

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6.4.2
Neurologic Adverse Event Management
Table 22. Neurologic Adverse Event Management Algorithm
At C1D1 of Crossover phase, baseline neuropathy: Grade ≤1
Grade of Neuropathy
 (NCI-CTCAE v4)
Management
Grade 1
• Continue nab-paclitaxel at same dose
Grade 2
• Reduce nab-paclitaxel one dose level (75 mg/m2)*
Grade 3
• First occurrence: Delay nab-paclitaxel until resolved to ≤ Grade 2 
and:
       • If prior dose 100 mg/m2: resume nab-paclitaxel with one dose 
level reduction (75 mg/m2).
       • If prior dose 75 mg/m2: resume nab-paclitaxel with another 
dose level reduction (50 mg/m2)
• Second occurrence: 
       • If prior dose 75 mg/m2: delay nab-paclitaxel until resolved to ≤ 
Grade 2 and resume nab-paclitaxel with another dose level reduction 
(75 mg/m2). If there is a third occurrence, discontinue nab-paclitaxel 
permanently. Continuing nivolumab is at physician´s discretion.
       • If prior dose 50 mg/m2: permanently discontinue nab-paclitaxel. 
Continuing nivolumab is at physician´s discretion.
Grade 4
Discontinue nab-paclitaxel permanently. Continuing nivolumab is at 
physician´s discretion.
ADL = activities of daily living; NCI-CTCAE v4 = National Cancer Institute Common  Terminology Criteria version 
4. 
At C1D1 of Crossover phase, baseline neuropathy: Grade 2
If prior to starting Crossover phase a patient has residual grade 2 neuropathy attributed to 
carboplatin, treatment with nab-paclitaxel should be initiated at one dose level reduction (75 
mg/m2).
Grade of Neuropathy
 (NCI-CTCAE v4)
Management
Grade 1
• Continue nab-paclitaxel at same dose
Grade 2
• Continue nab-paclitaxel at same dose
Grade 3
• First occurrence: delay nab-paclitaxel until resolved to ≤ Grade 2 
and resume with another dose level reduction (50 mg/m2)

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• Second occurrence: Discontinue nab-paclitaxel permanently. 
Continuing nivolumab is at physician´s discretion.
Grade 4
Discontinue nab-paclitaxel permanently. Continuing nivolumab is at 
physician´s discretion.
ADL = activities of daily living; NCI-CTCAE v4 = National Cancer Institute Common  Terminology Criteria version 
4.
6.4.3
Hepatobiliary Disorders
Since the exposure and toxicity of paclitaxel can be increased with hepatic impairment, 
administration of nab-paclitaxel in patients with hepatic impairment should be performed with 
caution. Patients with hepatic impairment may be at increased risk of toxicity, particularly from 
myelosuppression; such patients should be closely monitored for development of profound 
myelosuppression.
Table 23. Hepatobiliary Adverse Event Management Algorithm
Grade of Elevated AST, ALT or 
Bilirubin
(NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nab-paclitaxel at same dose
Grade 2
• Delay/omit nab-paclitaxel until it 
resolves to  ≤ Grade 1 or baseline, with 
the following exceptions:
a) Documented liver metastases and 
baseline AST or ALT > 3.0 to ≤ 5.0 x 
ULN
b) Documented Gilbert´s syndrome and 
baseline total bilirubin > 1.5 to ≤ 3.0 x 
ULN
If returns to ≤ Grade 1 or baseline:
• Resume nab-paclitaxel at same dose
Grade 3
• Delay/omit nab-paclitaxel until it 
resolves to  ≤ Grade 1 or baseline
If returns to ≤ Grade 1 or baseline:
• Resume nab-paclitaxel at one dose 
level reduction (75 mg/m2) for all 
subsequent cyclesa
Grade 4
• Discontinue nab-paclitaxel
ALT = alanine aminotransferase; AST = aspartate aminotransferase; LFT = liver function test; NCI-CTCAE v4 = 
National Cancer Institute Common Terminology Criteria version 4; ULN = upper limit of normal
a If a patient has persistent Grade 3 AE, a further dose level reduction (75 mg/m2) is allowed at physician´s 
discretion.

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6.4.4
Management of Nab-Paclitaxel Infusion-Related Reactions and Hypersensitivity
Severe and sometimes fatal hypersensitivity reactions, including anaphylactic reactions, have been 
reported. Patients who experience a severe hypersensitivity reaction to nab-paclitaxel should not 
be rechallenged with this drug (please see management and rechallenging instructions below). 
Cross-hypersensitivity between nab-paclitaxel and other taxane products has been reported and 
may include severe reactions such as anaphylaxis. Patients with a previous history of 
hypersensitivity to other taxanes should be closely monitored during initiation of nab-paclitaxel 
therapy, and premedication with diphenhydramine and corticosteroids may be considered per 
physician discretion.
Hypersensitivity reactions may occur within a few minutes following the initiation of the infusion 
of nab-paclitaxel. If hypersensitivity reactions occur, minor symptoms such as flushing or localised 
cutaneous reactions do not require discontinuation of therapy. The infusion may be temporarily 
interrupted and when symptoms improve re-started at a slower infusion rate. Chlorphenamine 
10mg iv may be administered. Severe reactions, such as hypotension, bronchospasm or generalized 
rash/erythema require immediate discontinuation of nab-paclitaxel and appropriate therapy.
Table 24. Nab-Paclitaxel Infusion-Related Reactions and Hypersensitivity Management
Grade of nab-Paclitaxel Infusion-
Related Reaction (NCI-CTCAE v4)
Management
Follow-up
Grade 1
• Continue nab-paclitaxel per protocol. 
Remain at beside.
• Institute prophylactic medications 
with subsequent infusions
Grade 2
• Hold nab-paclitaxel until resolution to ≤ 
Grade 1
• Refer to management and 
rechallenging instructions below
Grade 3
• For patients, infusion should be held 
until resolution to ≤ Grade 1
• If patient is not rechallenged, 
desensitization may be considered per 
physician discretion
Grade 4
• Discontinue nab-paclitaxel therapy
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4
For 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 nab-
paclitaxel administrations.

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For 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 nab-paclitaxel 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. Restart the infusion at 50% of the 
original infusion rate when symptoms resolve to Grade ≤ 1; if no further complications ensue after 
30 minutes, the rate may be increased to 100% of the original infusion rate. Monitor participant 
closely. If symptoms recur, then no further nab-paclitaxel will be administered at that visit. 
Administer diphenhydramine 50 mg IV, and remain at bedside and monitor the participant 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 nab-paclitaxel 
administration. If necessary, corticosteroids (recommended dose: up to 25 mg of IV 
hydrocortisone or equivalent) may be used.
For Grade 3 or Grade 4 symptoms: 
Grade 3: prolonged [e.g. not rapidly responsive to symptomatic medication and/or brief 
interruption of infusion]; recurrence of symptoms following initial improvement; hospitalization 
indicated for other clinical sequelae [e.g. renal impairment, pulmonary infiltrates).
Grade 4: life-threatening; pressor or ventilatory support indicated.
Immediately discontinue infusion of nab-paclitaxel. Begin an IV infusion of normal saline, treat 
with 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. 
Participant should be monitored until the investigator is comfortable that the symptoms will not 
recur. 
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 (e.g., appearance of a localized or generalized pruritis within 1 week 
after treatment), symptomatic treatment may be given (e.g., oral antihistamine, or corticosteroids). 
Desensitization is allowed for patients on nab-paclitaxel and may be considered per physician 
discretion. 
6.4.5
Management of All Other Adverse Events
Table 25: General Guidance for All Other Adverse Events 
Grade of Adverse Event
 (NCI-CTCAE v4)
Management
Grade 1-2
• Continue nab-paclitaxel at same dose

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Grade 3
• Delay/omit nab-paclitaxel until resolution to ≤ Grade 1 or baseline and 
resume nab-paclitaxel at one dose level reduction (75 mg/m2)a
Grade 4
• Discontinue nab-paclitaxel therapy
NCI-CTCAE v4 = National Cancer Institute Common Terminology Criteria version 4
a If a patient has persistent Grade 3 AE, a further dose level reduction (50 mg/m2) is allowed at physician´s 
discretion.
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The following 
list of reported and/or potential AEs (Section 7.1) and the characteristics of an observed AE 
(Section 7.2) will determine whether the event requires expedited reporting in addition to routine 
reporting.
7.1
Adverse Events List
7.1.1
Expected Adverse Events for Nivolumab
The PD-L1/PD-1 pathway is involved in peripheral tolerance and, therefore, its inhibition may 
increase the risk of immune-related AEs, specifically the induction or enhancement of autoimmune 
conditions. AEs with potentially immune-related causes, including rash, hypo-/hyperthyroidism, 
hepatitis/transaminitis, colitis, pneumonitis, hypophysitis, adrenal insufficiency, insulin-
dependent Diabetes Mellitus, myositis, and myasthenia gravis, have been observed.
For complete details on adverse reactions, please see nivolumab investigator brochure. 
7.1.2
Expected Adverse Events for Carboplatin
The following AEs related to the cytotoxic mechanism of action of carboplatin have been reported: 
Hematologic Toxicity 
Bone marrow suppression is the dose-limiting toxicity of carboplatin, including thrombocytopenia, 
neutropenia and anemia. Fever has also been reported in patients with neutropenia. The nadir of 
hematologic toxicity with single-agent carboplatin usually occurs at about day 21. Marrow 
suppression is usually more severe in patients with impaired kidney function. Patients with poor 
performance status have also experienced a higher incidence of severe leukopenia and 
thrombocytopenia. The incidence of anemia increases with increasing exposure to carboplatin.
Gastrointestinal Toxicity 
Carboplatin, as a single agent or in combination, is significantly less emetogenic than cisplatin; 
however, patients previously treated with emetogenic agents, especially cisplatin, appear to be 
more prone to vomiting. Both nausea and vomiting usually cease within 24 hours of treatment and 
are often responsive to antiemetic measures. Other gastrointestinal effects observed frequently 

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were constipation and diarrhea.
Neurologic Toxicity 
Peripheral neuropathies have been observed in patients receiving carboplatin, with mild 
paresthesias occurring most frequently. Carboplatin therapy produces significantly fewer and less 
severe neurologic side effects than does therapy with cisplatin. However, patients older than 65 
years and/or previously treated with cisplatin appear to have an increased risk for peripheral 
neuropathies. Although the overall incidence of peripheral neurologic side effects induced by 
carboplatin is low, prolonged treatment, particularly in cisplatin pretreated patients, may result in 
cumulative neurotoxicity.
Nephrotoxicity 
Development of abnormal renal function test results is uncommon, despite the fact that carboplatin, 
unlike cisplatin, has usually been administered without high-volume fluid hydration and/or forced 
diuresis. Creatinine clearance has proven to be the most sensitive measure of kidney function in 
patients receiving carboplatin, and it appears to be the most useful test for correlating drug 
clearance and bone marrow suppression. Patients with a baseline value of 60 mL/min or more are 
more likely to experience a reduction below this value during carboplatin therapy.
Hepatic Toxicity 
Abnormal liver function tests, including transaminitis, have generally been mild and reversible, 
although the role of metastatic tumor in the liver may complicate the assessment in many patients.
Electrolyte Changes 
The following serum electrolytes have been found to be anormally decreased with treatment with 
carboplatin: sodium, potassium, calcium and magnesium. Electrolyte supplementation is not 
routinely administered concomitantly with carboplatin, and these electrolyte abnormalities are 
rarely associated with symptoms.
Allergic Reactions 
Hypersensitivity has been reported with carboplatin. These allergic reactions have been similar in 
nature and severity to those reported with other platinum-containing compounds, ie, rash, urticaria, 
erythema, pruritus, and rarely bronchospasm and hypotension. Anaphylactic reactions have been 
reported as part of postmarketing surveillance. These reactions have been successfully managed 
with standard epinephrine, corticosteroid, and antihistamine therapy.
Injection Site Reactions 
Injection site reactions, including redness, swelling, and pain, have been reported during 
postmarketing surveillance. Necrosis associated with extravasation has also been reported. 
For complete details on adverse reactions please see the carboplatin package insert.
7.1.3
Expected Adverse Events for Nab-Paclitaxel
In clinical studies, nab-paclitaxel has been associated with alopecia, myelosuppression

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(primarily neutropenia), sensory neuropathy, abnormal ECG, fatigue/asthenia, myalgia/arthralgia, 
AST elevation, alkaline phosphatase elevation, anemia, nausea, infections, and diarrhea.
Participants will be monitored for nab-paclitaxel-related adverse events, including hematologic,
GI and hepatic toxicities, and peripheral neuropathy.
For more details regarding the safety profile of nab-paclitaxel, please refer to the ABRAXANE®
Package Insert.
7.2
Adverse Event Characteristics

CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 will be utilized for AE reporting. All appropriate treatment areas should have access 
to a copy of the CTCAE version 4.0. A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.

For expedited reporting purposes only:  
-
AEs for the agent(s) that are listed above should be reported only if the adverse event 
varies in nature, intensity or frequency from the expected toxicity information which 
is provided.
-
Other AEs for the protocol that do not require expedited reporting are outlined in the 
next section (Expedited Adverse Event Reporting) under the sub-heading of Protocol-
Specific Expedited Adverse Event Reporting Exclusions.

Attribution of the AE:
o
Definite – The AE is clearly related to the study treatment.
o
Probable – The AE is likely related to the study treatment.
o
Possible – The AE may be related to the study treatment.
o
Unlikely – The AE is doubtfully related to the study treatment.
o
Unrelated – The AE is clearly NOT related to the study treatment.
Expectedness of the AE:
Adverse events can be ‘Expected’ or “Unexpected’
o
Expected adverse event
Expected adverse events are those that have been previously identified as
resulting from administration of the agent. For the purposes of this study, an
adverse event is considered expected when it appears in the current adverse
event list, the Investigator’s Brochure, the package insert or is included in
the informed consent document as a potential risk.
Refer to Section 7 for a listing of expected adverse events associated with the study 
agent(s).

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o
Unexpected adverse event
For the purposes of this study, an adverse event is considered unexpected
when it varies in nature, intensity or frequency from information provided in
the current adverse event list, the Investigator’s Brochure, the package insert
or when it is not included in the informed consent document as a potential risk.
7.3
Expedited Adverse Event Reporting 
7.3.1
Investigators must report to the Overall PI any serious adverse event (SAE) that occurs 
after the initial dose of study treatment, during treatment, or within 30 days of the last 
dose of treatment (100 days for participants receiving nivolumab).  
7.3.2
For multi-institution studies where a DF/HCC investigator is serving as the Overall 
Principal Investigator, each participating institution must abide by the reporting 
requirements set by the DF/HCC. This applies to any medical event equivalent to an 
unexpected grade 2 or 3 with a possible, probable or definite attribution, unexpected 
grade 4 toxicities, and grade 5 (death) regardless of study phase or attribution.
7.3.3
Additionally, as mentioned in section 6.2.10, Nivolumab Infusion-Related Reactions, all 
Grade 3 or 4 infusion reactions should be reported within 24 hours to the study PI and 
reported as a SAE if criteria are met. 
7.3.4
All occurrences of potential DILIs, meeting the defined criteria in Section 5.5, must be 
reported as SAEs.
7.4
DF/HCC Expedited Reporting Guidelines
Investigative sites within DF/HCC will report AEs directly to the DFCI Office for 
Human Research Studies (OHRS) per the DFCI IRB reporting policy. 
Other investigative sites will report AEs to their respective IRB according to the local 
IRB’s policies and procedures in reporting adverse events. A copy of the submitted 
institutional AE form should be forwarded to the Overall PI within the timeframes 
detailed in the table below.  

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DF/HCC Reportable AEs
Attribution
Gr. 2 & 3 
AE
Expected
Gr. 2 & 3 AE 
Unexpected
Gr. 4 AE 
Expected
Gr. 4 AE
Unexpected
Gr. 5 AE 
Expected or 
Unexpected
Unrelated
Unlikely
Not required
Not required
5 calendar 
days#
5 calendar 
days
24 hours*
Possible
Probable
Definite
Not required
5 calendar 
days
5 calendar 
days#
5 calendar 
days
24 hours*
# If listed in protocol as expected and not requiring expedited reporting, event does not need to 
be reported.
* For participants enrolled and actively participating in the study or for AEs occurring within 
30 days of the last intervention (100 days for participants receiving nivolumab), the AE should 
be reported within 1 business day of learning of the event.
The Overall PI will submit AE reports from outside institutions to the DFCI OHRS 
according to DFCI IRB policies and procedures in reporting adverse events. 
7.5
Expedited Reporting to the Food and Drug Administration (FDA)
The Overall PI, as study sponsor, will be responsible for all communications with the FDA. The 
Overall PI will report to the FDA, regardless of the site of occurrence, any serious adverse event 
that meets the FDA’s criteria for expedited reporting following the reporting requirements and 
timelines set by the FDA.
7.6
Expedited Reporting to Hospital Risk Management
Participating investigators will report to their local Risk Management office any participant safety 
reports or sentinel events that require reporting according to institutional policy. 
7.7
Expedited Reporting to 
 
SAEs, whether related or not related to study drug, and pregnancies must be reported to 
 
within 24 buiness hours of the awareness of the event by the Overall PI. SAEs must be recorded 
on a Medwatch Form 3500A.
SAE Email Address:  
SAE Facsimile Number:  609-818-3804
If only limited information is initially available, a follow-up report is required and should  include 
the same investigator term(s) initially reported.

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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 of awareness to 
 
(or designee) using the same procedure used for transmitting the initial SAE report. 
All SAEs should be followed to resolution or stabilization.
7.7.1
SAE Definition for Reporting to 
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)

requires inpatient hospitalization or causes prolongation of existing 
hospitalization 

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.
A planned medical or surgical procedure is not, in itself, an SAE. 
7.7.2
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 
 of this event and complete 
one of the following forms within 24 hours of awareness of the 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.

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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,
 Pregnancy Surveillance Form, or approved site SAE form.  A 
 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 
 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.
7.8
Routine Adverse Event Reporting
All Grade 2 or higher Adverse Events (excluding non-clinically significant laboratory values) 
Adverse Events must be reported in routine study data submissions to the Overall PI on the toxicity 
case report forms. AEs reported through expedited processes (e.g., reported to the IRB, FDA, 
etc.) must also be reported in routine study data submissions.
8. PHARMACEUTICAL INFORMATION
A list of the adverse events and potential risks associated with the investigational agent(s) 
administered in this study can be found in Section 7.
8.1
Nivolumab
8.1.1
Description
Nivolumab is also referred to as BMS-936558-01 or BMS-936558. Nivolumab is a soluble protein 
consisting of 4 polypeptide chains, which include 2 identical heavy chains and 2 identical light 
chains. The physical and chemical properties of nivolumab are provided in Table 8.1.1 below. The 
geometric mean elimination half-life (t½) was 25 days and the typical clearance was 8.2 mL/h, 
which are consistent with those of full human immunoglobulin antibodies.
Table 26: Nivolumab Physical and Chemical Properties
Number
BMS-936558-01
Other Names
Nivolumab, BMS-936558, MDX1106, ONO-4538, anti-PD-1
Molecular Weight
146,221 daltons
Appearance
Clear to opalescent, colorless to pale yellow liquid, light (few) 
particulates may be present
Solution pH
5.5 to 6.5

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8.1.2
Storage and Stability
Vials of Nivolumab injection must be stored at 2°-8°C (36°-46°F) and protected from light, 
freezing and shaking. Shelf-life surveillance of the intact vials is ongoing.
The administration of undiluted and diluted solutions of Nivolumab must be completed within 24 
hours of preparation. If not used immediately, the infusion solution may be stored up to 24 hours 
in a refrigerator at 2°-8°C (36°-46°F), with a maximum of 8 hours of the total 24 hours at room 
temperature (20°-25°C, 68°-77°F) and room light. The maximum 8-hour period under room 
temperature and room light conditions includes the product administration period.
CAUTION: The single-use dosage form contains no antibacterial preservative or bacteriostatic 
agent. Therefore, it is advised that the product be discarded 8 hours after initial entry.
8.1.3
Compatibility
No incompatibilities between Nivolumab injection and polyvinyl chloride (PVC), non-PVC/non-
DEHP (di(2-ethylhexyl)phthalate) IV components, or glass bottles have been observed. 
8.1.4
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and the 
environment, should undertake the preparation, handling, and safe disposal of the 
chemotherapeutic agent in a self-contained and protective environment. 
8.1.5
Availability
Pharmaceutical Management Branch, CTEP/DCTD/NCI as 100 mg vials (10 mg/mL) with a 
0.7mL overfill. It is supplied in 10 mL type I flint glass vials, with butyl rubber stoppers and 
aluminum seals.
8.1.6
Preparation
Nivolumab is available as 100 mg vials (10 mg/mL), which include an overfill. It is 
supplied in 10 mL type I flint glass vials, with butyl stoppers and aluminum seals. Nivolumab 
injection can be infused undiluted (10 mg/mL) or diluted with 0.9% Sodium Chloride Injection, 
USP or 5% Dextrose, USP to concentrations no less than 0.35 mg/mL. When the dose is fixed (eg, 
360 mg flat dose), nivolumab injection can be infused undiluted or diluted so as not to exceed a 
total infusion volume of 160 mL.
8.1.7
Administration
Nivolumab will be delivered in infusion bags with IV infusion lines over approximately 30 minutes 
(+/- 10 minutes) using a volumetric pump with 0.2 to 1.2 micron pore size, low-protein binding 
polyethersulfone membrane in-line filter. 

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8.1.8
Ordering
Nivolumab will be provided by 
. Each participating institution is responsible for completing 
the applicable drug supply forms to receive re-supply of Nivolumab for the duration of study. 
Except in very unusual circumstances, each participating institution will order the study agent(s). 
A participating site may order the agent(s) only after the initial IRB approval for the site has been 
forwarded by the Coordinating Center to the supplier.
8.1.9
Accountability
The investigator, or a responsible party designated by the investigator, should maintain a careful 
record of the inventory and disposition of the agent using the NCI Drug Accountability Record 
Form (DARF) or another comparable drug accountability form. (See the NCI Investigator’s 
Handbook for Procedures for Drug Accountability and Storage.)
8.1.10 Destruction and Return
At the end of the study, unused supplies of nivolumab should be destroyed according to 
institutional policies. Destruction will be documented in the Drug Accountability Record Form.
8.2
Carboplatin
8.2.1
Description 
Carboplatin is a platinum coordination compound. The chemical name for carboplatin is 
platinum, diammine[1,1-cyclobutanedicarboxylato(2-)- O,O′]-, (SP-4-2), and carboplatin has the 
following structural formula:
Carboplatin is a crystalline powder with the molecular formula of C6H12N2O4Pt and a molecular 
weight of 371.25. It is soluble in water at a rate of approximately 14 mg/mL, and the pH of a 1% 
solution is 5 to 7. It is virtually insoluble in ethanol, acetone, and dimethylacetamide.
8.2.2
Formulation and Administration
Carboplatin will be obtained commercially and is available as a sterile, pyrogen-free, 10 mg/mL 
aqueous solution in 5-mL, 15-mL, 45-mL, and 60-mL vials. Carboplatin may be diluted in 0.9% 
sodium chloride injection, USP or 5% dextrose injection, USP. Needles or IV administration sets 
containing aluminum parts that may come in contact with carboplatin should not be used for the 
preparation or administration of the drug. Aluminum can react with carboplatin causing precipitate 
formation and loss of potency.

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The total dose of carboplatin for each patient will be per institutional guidelines. Carboplatin 
should be administered after nivolumab. Carboplatin as well as premedication is to be administered 
and stored in accordance with local prescribing information and local institutional guidelines. 
8.2.3
Storage and Stability 
Carboplatin is a premixed aqueous solution of 10 mg/mL that can be further diluted to 
concentrations as low as 0.5 mg/mL with 5% dextrose in water (D5W) or 0.9% sodium chloride 
injection, USP. When prepared as directed, carboplatin aqueous solutions are stable for 8 hours at 
room temperature (25°C). Since no antibacterial preservative is contained in the formulation, it is 
recommended that carboplatin aqueous solutions be discarded 8 hours after dilution.
Unopened vials of carboplatin are stable to the date indicated on the package when stored at 25°C 
(77°F); excursions permitted from 15°-30°C (59°-86°F). Vials should be protected from light. 
Carboplatin multidose vials maintain microbial, chemical, and physical stability for up to 14 days 
at 25°C following multiple needle entries. Parenteral drug products should be inspected visually 
for particulate matter and discoloration prior to administration. Solutions for infusion should be 
discarded 8 hours after preparation.
8.2.4
Handling 
Qualified personnel, familiar with procedures that minimize undue exposure to
themselves and the environment, should undertake the preparation, handling, and safe
disposal of the chemotherapeutic agent in a self-contained and protective environment.
8.2.5
Availability
Carboplatin is commercially available.
8.2.6
Preparation 
Carboplatin should be prepared according to institutional guidelines.
8.2.7
Ordering
Carboplatin is commercially available. Check with the site Director of Pharmacy and/or the
site research pharmacy to ensure that the agent is in stock. If the agent is not stocked,
ensure that the agent can be ordered before the protocol is activated. 
For complete details on drug preparation, administration, storage conditions, clinical 
pharmacology, pharmacokinetics, known precautions, warnings and adverse reactions please see 
the carboplatin package insert.
8.3
Nab-Paclitaxel
Please refer to the FDA-approved package insert for nab-paclitaxel for product information,
extensive preparation instructions, and a comprehensive list of adverse events.

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8.3.1
Description 
ABRAXANE® for Injectable Suspension (paclitaxel protein-bound particles for injectable
suspension) (albumin-bound) is an albumin- bound form of paclitaxel with a mean particle
size of approximately 130 nanometers. Paclitaxel exists in the particles in a non crystalline,
amorphous state. ABRAXANE® is free of solvents.
The active agent in ABRAXANE® is paclitaxel, a microtubule inhibitor. The chemical
name for paclitaxel is 5β,20-Epoxy 1,2α,4,7β,10β,13α-hexahydroxytax-11-en-9-one 4,10-
diacetate 2-benzoate 13-ester with (2R,3S)-N-benzoyl-3-phenylisoserine.
Paclitaxel has the following structural formula:
Paclitaxel is a white to off-white crystalline powder with the empirical formula
C47H51NO14 and a molecular weight of 853.91. It is highly lipophilic, insoluble in water,
and melts at approximately 216°C to 217°C.
8.3.2
Storage and Stability
Store vials in original cartons at room temperature (20°C-25°C; 68°F-77°F). Retain the
original package to protect from bright light. Unopened vials of albumin-bound paclitaxel
are stable until the date indicated on the package when stored at the above temperature in
the original package.
Reconstituted vials of nab-paclitaxel may be refrigerated at (2°C-8°C; 38°F-46°F) for a
maximum of 8 hours and should be protected from bright light.
8.3.3
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves
and the environment, should undertake the preparation, handling, and safe disposal of the
chemotherapeutic agent in a self-contained and protective environment.
8.3.4
Availability
Nab-paclitaxel is commercially available and will be obtained from the Institutional
pharmacy.

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8.3.5
Preparation
Reconstitute each vial with 20 mL of 0.9% Sodium Chloride Injection, USP injected over
at least 1 minute. Direct the NaCl onto the inside wall of the vial, and not directly onto the
lyophilized cake, as this will result in foaming. Following reconstitution, allow the vial to
sit for a minimum of 5 (five) minutes to ensure proper wetting of the lyophilized
cake/powder. Gently swirl and/or invert the vial slowly for at least 2 minutes until complete
dissolution of any cake/powder occurs. Rapid agitation or shaking will result in foaming.
If foaming or clumping occurs, stand solution for at least 15 minutes until foam subsides.
The reconstituted suspension should appear milky and homogeneous without visible
particulates. If unsuspended powder is visible, the vial should be gently inverted again to
ensure complete resuspension, prior to use. Each mL of reconstituted product will contain
5 mg of paclitaxel. Withdraw the desired volume and inject the suspension into an empty
sterile PVC container.
Parenteral drug products should be inspected visually for particulate matter and
discoloration before administration whenever the solution and container permit. The
reconstituted sample should be milky and homogenous, without visible particulates. If
particulates are visible or settling occurs, the vial should be gently inverted to ensure
complete resuspension before use.
8.3.6
Formulation and Administration
Nab-paclitaxel is available in single use vials containing 100 mg of paclitaxel as a
lyophilized powder.
Nab-paclitaxel will be administered intravenous infusion over 30 minutes. Filters are not
required for preparation or administration of nab-paclitaxel. If filters are used as part of
institutional procedure, the pore size must be > 15 micron.
8.3.7
Ordering
Nab-paclitaxel is commercially available and will be ordered per the standard practices of
the Institutional pharmacy.
8.3.8
Accountability
Nab-paclitaxel is a commercially available product. Accountability will be handled per
institutional polices regarding commercial products.
8.3.9
Destruction and Return
Nab-paclitaxel is a commercially available product. Destruction and return will be
handled per institutional policies regarding commercial products.
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES
All biomarker analyses completed on blood and tissue samples for correlative data will be
exploratory.

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In all patients in whom tumor is safely accessible, a baseline tumor biopsy is required. We plan to 
use baseline biopsy tissue to perform immune profiling assays, characterization based on histology 
(TILs), protein expression, and mRNA expression, as detailed below. We will perform targeted 
panel (OncoPanel) and whole exome sequencing to determine mutational load and identify specific 
mutations or copy number changes in a panel of DNA repair genes and other potential biomarkers 
of interest. Additionally, we will bank specimens for possible future additional analyses.
We will perform single-cell RNA sequencing on the study biopsies for up to 15 first-line 
carboplatin-nivolumab patients, up to 15 first-line carboplatin patients and up to 15 second-line 
nab-paclitaxel-nivolumab patients enrolled at DFCI. These single-cell RNA studies will 
distinguish immune cell populations associated with response to carboplatin and nivolumab. 
Additionally, the studies will evaluate subclonal intratumor heterogeneity and characterize tumor 
subpopulations associated with resistance to therapy.
Serial blood draws for correlative science are required on this trial; blood draws will be obtained 
every two cycles (every 6 weeks during the Treatment Phase, every 8 weeks during the Crossover 
Phase) prior to the infusion of study drugs for the first 24 weeks on study treatment and then every 
three cycles (every 9 weeks during the Treatment Phase, every 12 weeks during the Crossover 
Phase), at the end-of-treatment visit in patients who go off treatment for progressive disease, and 
all efforts will be made to obtain an additional blood draw at the time of progressive disease, in 
patients who went off treatment for any reason other than progressive disease. Blood will be 
collected for flow cytometry to characterize protein expression of immune mediators and for T-
cell receptor (TCR) sequencing, as detailed below, and additional blood will be banked for future 
analyses.
Instructions for the collection, labeling and shipment of blood, tissue, and stool samples are 
outlined below and further detailed in the 17-512 Lab Manual . 
Please note that some of the downstream correlative plans for blood and tissue include whole 
exome sequencing, RNA sequencing, tumor tissue spatial profiling, single cell sequencing, 
single-nucleus sequencing, and TCR sequencing plus analysis of the data generated, which may 
be performed at the Broad Institute of MIT, Nanostring Technologies, Inc., Adaptive 
Biotechnologies, and Foundation Medicine. All samples will be sent in a completely de-
identified fashion. Gene expression assays (e.g. BC360 panel) and digital spatial profiling (DSP) 
will be performed at DFCI and/or BWH Pathology using FFPE tissue samples. De-identified 
gene-expression and/or DSP data will be analyzed by Nanostring and returned to the PI, 
following the corresponding MTA. Only designated study personnel at DFCI will have access to 
PHI.

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Specimen Collection Table
Specimen
Screening
Cycle 1
Day 1
Cycle 2
Day 1
Cycle 3
Day 1
Subsequent 
Cycles
Day 1
End of 
treatment/ 
Progression d
Shipping Condition
Ship to
Lavender Top 
Tube (Section 9.3)
x
Ambient
Core Blood and 
Tissue Bank
Streck Tube
(Section 9.3)
x 
x
x a
x c
Ambient
Core Blood and 
Tissue Bank
Green Top Tubes
(Section 9.3)
x
x
x a
x c
Ambient
CIO/Marianno’s 
Lab
Archival tumor 
tissue (blocks or 
slides) 
(Section 9.1)
x
Ambient
DFCI 17-512 
Study Team
Required fresh 
tumor tissue 
biopsy b 
(Section 9.2)
 x
x
x d
FFPE, RNAlater: 
Ambient
DMEM: 4ºC (ice packs)  
OCT: Frozen 
Core Blood and 
Tissue Bank: 
OCT, RNAlater,
FFPE/formalin

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a.
Every 6 weeks (coinciding with day 1 of that cycle) for 24 weeks, then every 9 weeks. For Arm B 
participants who elect to cross-over to nivolumab + nab-paclitaxel, every 8 weeks (coinciding with 
day 1 of that cycle) for 24 weeks, then every 12 weeks. 
b.
Fresh tumor biopsy of accessible metastatic lesion is mandatory before treatment begins. The biopsy 
may be performed at screening or on Cycle 1 Day 1 prior to dosing. For external site patients, 
biopsy should be done after registration or on C1D1 prior to treatment start. See section 9.2 below.  
c.
Blood samples are mandatory for patients with progressive disease. For patients who come off 
treatment for other reasons, blood samples are optional at end of treatment and every 6-12 weeks 
during follow up. For Arm B participants who elect to cross-over to nivolumab + nab-paclitaxel, 
the study calendar is reinitated at C1D1 for Streck and Green Top tube collections (Lavender Top 
tube is not required). See Section 10, Study Calendar.
d.
For Arm B participants who elect to cross-over to nivolumab + nab-paclitaxel, a baseline biopsy is 
mandatory, if safely accessible, before treatment begins. The study calendar is reinitiated for tissue 
collection during the Crossover phase.
e.
Dietary and physical activity questionnaires will be performed at the time points of stool sample 
collection.
f.
Stool sample will be collected at time of progression if response was observed with treatment and 
for Arm B participants who elect to cross-over to nivolumab + nab-paclitaxel before treatment 
begins. The study calendar is reinitiated for stool sample collection during the Crossover phase.
g.
 Only for specific subset of patients enrolled at DFCI, See Section 9.2.3.
9.1
Archival Tissue 
9.1.1
Collection
At least one formalin-fixed, paraffin-embedded (FFPE) tumor block or 10-20 (5 micron) unstained 
charged slides will be collected from archival tissue for future research for all participants. Tissue 
from time of diagnosis is preferred, but if not available, then any archival sample prior to receipt 
of the previous line of treatment is acceptable. Tissue needs to be located and availability must be 
confirmed at the time of registration, as indicated in eligibility criterion 3.1.4. Tissue may be 
shipped to the DFCI 17-512 study team after registration occurs. 
9.1.2
Shipping of Specimen(s) 
All sites will ship archival specimens at ambient temperature to:
(dry ice) 
RPMI w/ Hepes: 4ºC 
(ice packs)f
CIO/Marianno’s 
Lab: DMEM
CCPM Team: 
RPMI w/ Hepesg
Optional fresh 
tumor tissue 
biopsy
(Section 9.2)
x
FFPE, RNAlater: 
Ambient
DMEM: 4ºC (ice packs)  
OCT: Frozen 
(dry ice)
Core Blood and 
Tissue Bank: OCT, 
RNAlater,
FFPE/formalin
CIO/Marianno’s 
Lab: DMEM
Stool sample 
collection e
(Section 9.4)
x
x
x f
Ambient
Biorepository  

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Dana-Farber Cancer Institute
Breast Oncology
Attn: DFCI 17-512 Study Team
450 Brookline Avenue
Dana 157
Boston, MA 02215
Email the current Dana-Farber CRC with the sample information and tracking information the day 
before shipping specimens. 
Complete a Specimen Requisition Form (17-512 Lab Manual) to be sent with the specimens; make 
a copy of the requisition for the participant’s research chart prior to sending. 
9.2
Fresh Tissue Biopsy 
9.2.1
Objectives
The study will obtain paired tumor biopsies for patients enrolled (after carboplatin monotherapy
and after carboplatin in combination with nivolumab). Paired biopsies will be used to evaluate
changes in TILs, expression of immune markers (e.g., immune cell subsets, inhibitory and co-
stimulatory pathway molecules by immunohistochemistry and/or immunofluorescence) and other 
relevant markers. Additionally, the biopsies will be subjected to whole exome sequencing (WES) 
to characterize mutational load, to capture BRCA reversion mutations (and the mutation status of 
most genes involved with double strange break repair), and overall mutational signature. A portion 
of the biopsies will be used to perform single-cell RNA sequencing to determine mRNA 
expression signatures in tumor and immune cells that correlate with response and resistance to 
treatment.
9.2.2
Collection of Specimen(s)
Biopsies will be performed at the below timepoints, if tumor is safely accessible for biopsy. 
Mandatory:

Baseline or on C1D1 prior to dosing (for external site patients, biopsy should be performed 
after registration or on C1D1 prior to dosing*)

After 3-6 weeks of treatment (any time from C2D1-C3D1)
Optional:

At time of progression
* Biopsies performed during screening prior to registration are not violations.
Crossover
For patients randomized to carboplatin monotherapy and who elect to crossover to nivolumab + 
nab-paclitaxel at time of progression, biopsies will be performed at the below timepoints:

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Mandatory:

Prior to initiation of nivolumab + nab-paclitaxel (baseline or C1D1 of crossover).

After 3-6 weeks of crossover treatment (any time from C2D1-C3D1)
Optional:

At time of progression on nivolumab + nab-paclitaxel
Retreatment 
For patients proceeding to the retreatment phase, biopsies will be performed at the below 
timepoints: 
Optional:

At time of progression, prior to restarting nivolumab 

After retreatment with nivolumab, at time of progression 
Mandatory biopsies of safely accessible tumor, at baseline and prior to crossover, if applicable, 
should be performed within 14 days of initiating therapy.
If dosing is delayed placing the biopsy outside of the allowable window, the biopsy should be 
rescheduled to be within the window. If not feasible, the biopsy should be obtained as close to 
within the window as possible. Tissue specimens will be collected from recurrent or metastatic 
lesions using standard institutional procedures. The amount of tissue collected will follow the 
guidelines listed below. If a participant has more than one site of disease, only one site needs to be 
biopsied in order to go on to the study and the site is left to the discretion of the patient and their 
treating physician. Fine need aspirates (FNA) are not allowed. Participants who undergo a research 
biopsy procedure for the purpose of this protocol, and in whom inadequate tissue is obtained, are 
still eligible and are not required to undergo a repeat biopsy in order to enter the study.

Breast: A goal of 3-6 core biopsy specimens will be obtained using standard institutional 
guidelines for a diagnostic core biopsy of a breast mass.

Skin/chest wall: A goal of 1-2 5-mm punch biopsies will be obtained.

Lymph node: A goal of 3-6 core biopsy specimens will be obtained using an 18-gauge 
needle.

Liver: A goal of 3-6 core biopsy specimens will be obtained using an 18-gauge needle.

Lung: Because of the risk of pneumothorax associated with core needle biopsies of lung 
nodules, no core biopsies of lung nodules will be performed on this protocol, unless they 
are clinically indicated.

Bone: Because the yield of malignant tissue from bone biopsies tends to be relatively low, 
if a participant has another accessible site of disease (i.e. skin, lymph node, liver), that site 
should be biopsied preferentially. If bone is the only biopsy-accessible site, then a goal of 
3-6 core biopsy specimens will be obtained using an 11-13 gauge needle.

Pleural fluid: A goal of 500 cc of pleural fluid will be obtained with a standard 
thoracentesis procedure, with or without image guidance, according to the clinical 
judgment of the treating physician and clinician performing the procedure. Less than the 

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goal amount is acceptable, and should be based upon the clinical judgment of the 
Investigator and the clinician performing the procedure. If more than the goal amount of 
fluid is obtained, then the entire specimen (with the exception of what is needed for clinical 
purposes, if applicable) will be stored in the tissue bank.

Ascites fluid: A goal of 500 cc of ascites fluid will be obtained with a standard paracentesis 
procedure, with or without image guidance, according to the clinical judgment of the 
treating physician and clinician performing the procedure. Less than the goal amount is 
acceptable, and should be based upon the clinical judgment of the Investigator and the 
clinician performing the procedure. If more than the goal amount of fluid is obtained, then 
the entire specimen (with the exception of what is needed for clinical purposes, if 
applicable) will be stored in the tissue bank.
Please note that the above are guidelines for the amount of tissue to be obtained at the baseline 
biopsy, and are not meant to replace clinical judgment at the time the procedure is performed. Less 
than the goal quantity of tissue is accepted for each type of biopsy, and will be left to the clinical 
judgment of the physician performing the procedure. If ascites or pleural fluid is to be used as the 
investigational biopsy specimen, consideration should be given to confirming the malignant nature 
of the ascites or pleural fluid prior to study entry.
If a patient is undergoing resection of a lesion for clinical reasons (i.e. wedge resection of a new 
lung lesion for confirmation of diagnosis or re-testing of hormone receptor or HER2 status; or, 
resection of a chest wall lesion; or, resection of a lymph node), then the patient may opt to have a 
portion of that tissue stored for research at the time of the procedure (provided that the tissue is 
collected and processed as specified in this section and the 17-512 Lab Manual), in which case, 
the participant would not be required to undergo a separate research biopsy for entry into this 
protocol.
9.2.3
Handling and Shipping 
Core biopsy specimens will be handled and processed at the time of biopsy collection. Ideally,
sufficient core biopsy samples will be obtained to allow for some to be frozen (after embeding 
in OCT) and others to be fixed in formalin and subsequently embedded into paraffin blocks. The 
specific instructions for handling core biopsy material is provided in the 17-512 Lab Manual 
The order of specimen collection should be:

First core: 10% neutral buffered formalin

Second core: RNA later 

Third core: Sterile DMEM 

Fourth core: Sterile DMEM*

Fifth core: OCT

Sixth core: 10% neutral buffered formalin
*If at least four cores cannot be obtained in a biopsy (allowing for 2 cores [third and fourth] to be 
collected in sterile DMEM), then the third core should be snap-frozen in OCT.

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For up to 15 first-line carboplatin-nivolumab patients, up to 15 first-line carboplatin patients and 
up to 15 second-line nab-paclitaxel-nivolumab patients enrolled at DFCI, the order of specimen 
collection will be: 

First core: 10% neutral buffered formalin

Second core: RPMI with Hepes

Third core: RPMI with Hepes

Fourth core: RNA later

Fifth core: OCT

Sixth core: 10% neutral buffered formalin
For DF/HCC Collaborative Sites ONLY, fresh tumor tissue in DMEM will not be collected at 
the time of the research biopsies due to shipping and processing requirements.
The order of specimen collection for DF/HCC Collaborative sites should be:

First core: 10% neutral buffered formalin

Second core: RNA later

Third core: OCT

Fourth core: 10% neutral buffered formalin

Fifth core: 10% neutral buffered formalin

Sixth core: 10% neutral buffered formalin
After being obtained, processing of the cores is as follows:

All samples should be de-identified and labeled with the participant initials, study ID, date 
of collection, approximate time of collection, and study time point.

Two cores in sterile DMEM should be brought as fresh tissue immediately to the lab to be 
processed for TILs within 1.5 hours of its collection (as described in the 17-512 Lab 
Manual). Sites processing DMEM cores locally will batch ship to Mariano Severgnini at 
the end of the study. For samples that will be processed at DFCI, the cores should be 
brought or shipped on ice to the lab of Mariano Severgnini at: 
Center for Immuno-Oncology
Dana-Farber Cancer Institute
440 Brookline Ave-Mayer 308
Boston, MA 02215
Phone: (617) 632-2421
Pager: 42093

Two cores in formalin should be made into a formalin-fixed paraffin-embedded (FFPE) 
block. Blocks should be brought/shipped ambient to the DF/HCC Core Blood and Tissue 
Bank (dfcibreastbank@partners.org). For local sites, the cores in formalin will be brought 
to the Brigham and Women’s Specialized Histopathology Core Lab where it will be made 
into a block. 

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
One core in OCT should be brought/shipped to the DF/HCC Core Blood and Tissue Bank 
Please email the DF/HCC Core Blood and Tissue Bank (dfcibreastbank@partners.org) 
with patient name, study ID, date of collection, approximate time of collection, and study 
time point the day prior to collection. 

One core in RNAlater should be brought/shipped at ambient temperature to the DF/HCC 
Core Blood and Tissue Bank. Please email the DF/HCC Core Blood and Tissue Bank 
(dfcibreastbank@partners.org) with patient name, study ID, date of collection, 
approximate time of collection, and study time point the day prior to collection. 
Ship specimens overnight Monday-Thursday only by either FedEx or UPS to::
Core Blood and Tissue Bank
Brigham and Women’s Hospital
Thorn Building – Room 428
20 Shattuck Street
Boston, MA 02215
dfcibreastbank@partners.org
Specific to the DFCI patients undergoing single-cell RNA sequencing:

Two cores in RPMI with Hepes: should be brought immediately to the lab at the Broad 
for processing. Members of the Center for Cancer Precision Medicine (CCPM) team will 
collect these cores to deliver them to the Broad Institute. Please email Laura Dellostritto 
(laura_dellostritto@dfci.harvard.edu) with study ID, study timepoint, tissue site, and 
collection date, location, and approximate time at least 24 hours prior to the collection.  
Tissue remaining after specific protocol testing described below will be banked in the Core Blood 
and Tissue Bank and may be used for additional or future analyses as needed.
Genomic sequencing as described below will be performed at the Broad Institute.
9.2.4
Potential Testing
Assay 1: Tumor infiltrating lymphocyte (TIL) percentage and determination of lymphocyte 
predominant breast cancer (LPBC)

Paraffinized, hematoxylin and eosin-stained slides taken from 1-2 tissue planes will be 
derived from each biopsy and will be reviewed by certified pathologists.  In the research 
setting, all cases are reviewed by two pathologists and any discordant results resolved by 
consensus review. The extent of lymphocytic infiltrate in tumor tissue will be assessed, and 
stromal TIL percentage will be determined. More detailed guidelines for the quantification 
of stromal TILs in breast cancer can be found in the recommendations from the 
International TILs Working Group 2014(114).

After assessment of the TIL percentage, the pathologists will categorize the specimen as 
lymphocyte predominant breast cancer (LPBC), defined as a tumor that contains >60% 

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stromal lymphocytes, or non-LPBC.
Assay 2: Immunohistochemistry and immunofluorescence assays

Tissue will be collected and fixed by 10% neutral buffered formalin overnight, dehydrated, 
and paraffin embedded. Four micrometer-thick sections will be cut. The paraffin blocks 
and unstained slides will be stored at room temperature. All immunohistochemical staining 
will be performed in the Center for Immuno-Oncology Pathology Core at Dana-
Farber/Harvard Cancer Center (DF/HCC) Specialized Histopathology Core.

Formalin fixed-paraffin embedded (FFPE) tumor slides will be prepared and H&E stained 
for assessment of TIL in pre- and post-treatment tumor samples. Subsets of different 
immune populations (effector/memory CD8 cells, T regulatory cells, dendritic cells, tumor 
associated macrophages, and Tie-2 expressing monocytes (TEM)) will be identified using 
immunohistochemical (IHC) and/or immunofluorescence (IF) staining on FFPE tumor 
slides.

Pathologic confirmation of PD-L1 status (no PD-L1 assay restriction) is required prior to 
enrollment on the trial for stratification purposes. Independent central confirmation of PD-
L1 status will be performed using the antibody clone SP142, as specified in Section 9.6. 
Investigators at our institution have developed IHC staining on paraffin embedded tissues 
for PD-L1, PD-L2, TIM-3, and LAG-3 through our center for Immuno-Oncology 
Pathology Core. PD-L1 IHC assays have recently been established in a CLIA approved 
laboratory and the remaining assays for CLIA laboratory conduct are being finalized. 
These investigators have published the methods, protocols, and data establishing the 
sensitivity and specificity of IHC staining assays using the monoclonal antibodies 
recognizing PD-L1 (CD274, B7-H1, antibody clone 7G11, generated in the lab of Gordon 
Freeman, DFCI) and PD-L2 (CD273, B7-DC, clone 9E5, generated in the laboratory of 
Gordon Freeman, DFCI)(115, 116). Other commercially available IHC PD-L1 antibodies 
(e.g. 28-8, SP263, 22C3, E1L3N) may be used to compare PDL1 staining.
As specified in Section 9.6, central confirmation of PD-L1 status will be performed using 
the antibody clone SP142 on the baseline research biopsy; if a baseline biopsy was not 
performed, archival tissue will be used for central confirmation of PD-L1 status. Tumor 
and immune cell expression of PD-L1 will be evaluated at different cut-off points (i.e. 1%, 
5%, 10%, 50%). Tumor will be considered positive if ≥1% (PD-L1)(71) of the immune 
cell infiltrate demonstrates unequivocal staining with SP142 on the Ventana platform. All 
IHC stained slides will be evaluated by a pathologist and H-scores will be reported. A 
subset of slides will be reviewed by a second pathologist to ensure concordance of 
interpretation.
The semi-quantitative scoring for this study is in accordance with those published 
previously and, as described above, will include scores for both the neoplastic and non-
neoplastic cells within the tumor microenvironment. Data derived from pathologist visual 
scoring (semi-quantitative, but with increased specificity for delineating neoplastic and 

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non-neoplastic cells) and pathologist-assisted, automated scoring (quantitative, but without 
accurately delineating neoplastic and non-neoplastic cells) for each marker of interest will 
be assessed for its clinical value. As necessary, the data from combinations of markers will 
also be considered (i.e. combined scores from PD-L1 and PD-L2 expression). All data will 
be analyzed in conjunction with the biostatistics group.

FFPE tumor slides will also be assessed by IHC and/or IF assays (e.g. GeoMx DSP) for 
other markers, including androgen receptor (AR), as deemed appropriate and informative 
based on the literature at the time of correlative science performance. 
Assay 3: Flow cytometry
TILs will be isolated from the biopsy specimen as described in the 17-512 Lab Manual. Surface 
staining followed by flow cytometry on the resultant TILs will then be performed as described in 
the 17-512 Lab Manual with a selection of antibodies, as deemed appropriate and informative 
based on the state of the immune profiling literature at the time of correlative science performance.
Assay 4: RNA analysis:
RNA analysis may be performed, and tissue for RNA analysis will be stored, in the Core Blood 
and Tissue Bank. Messenger RNA (mRNA) expression within tumor biopsy specimens may be 
assessed using the most current and informative methodologies at the time that correlative science 
is performed on all specimens. NanoString signatures and comprehensive RNA sequencing may 
be used. Potential genes of interest, based on prior immune profiling of breast tumors(56), include 
CXCL9, CCL5, CD8ACD80, CXCL13, IGKC, CD21, IDO1, PD-1, PD-L1, PD-L2, CTLA4, and 
FOXP3.
Perou and others have previously shown that within TNBC, exists all of the intrinsic subtypes of 
breast cancer. Thus, we propose to use the PAM50 algorithm(117) and the Claudin-low 
predictor(118) in order to determine the intrinsic subtype of each sample. Specifically, using the 
RNA-seq data, a global normalization step will be performed to adjust the TNBC RNA-seq data 
obtained in this study relative to the TNBC subset of patients coming from the TCGA RNA-seq 
study. Once this normalization is complete, the PAM50 algorithm will be run as described in 
Parker et al. 2009, and then the Claudin-low predictor run as described in Prat et al., thus 
classifying samples into 1 of 6 intrinsic subtypes. The intrinsic subtype classifications will be 
tested for associations with disease response to treatment using univariate and multivariate testing, 
in models that include the standard clinical parameters and with models including other genomic 
predictors.
For a subset of patients, single-cell or single-nuclei RNA sequencing will be performed on biopsies 
at baseline, on treatment, and, when available, on progression. These studies will determine 
whether changes in RNA expression signatures specific to tumor and immune cells correlate with 
treatment response and resistance. The analyses will also investigate whether particular immune 
cell subsets are enriched in responders compared to non-responders, as suggested by studies in 
other tumors treated with checkpoint inhibitors.

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Assay 5: Whole Exome, Whole Genome sequencing, DNA methylation
DNA sequencing will be performed at the Broad Institute; this may include SNP-arrays for DNA 
copy number changes as well as exome and/or whole genome sequencing. Tumor biopsy 
specimens may be assessed using the most current and informative methodologies at the time that 
correlative science is performed. Potential assays that may be performed on frozen or FFPE 
metastatic samples and/or FFPE primary samples include:

Whole Genome sequencing depth of ≥ 40X coverage, or Whole Exome sequencing depth 
of ≥ 500X coverage. 

AFFY SNP 6.0, or Illumina SNP arrays for genotypes and DNA copy number changes may 
be performed.

DNA methylation: Illumina Infinium 450K methylation arrays.
Assay 6: T-cell receptor (TCR) sequencing
DNA will be extracted from tumor tissue samples and submitted to Adaptive Biotechnologies for 
survey level TCR β-chain sequencing. Tumor biopsy specimens may be assessed using the most 
current and informative methodologies at the time that correlative science is performed. Potential 
testing includes: preparation of targeted amplicon libraries by multiplex PCR targeting all TCR β-
chain V and J gene segments, and then sequencing using Illumina HiSeq. Data for individual TCR 
sequences, including V and J gene segment identification and CDR3 sequences, can be obtained 
for customized analysis of T-cell repertoire diversity dynamics, as previously described(119).
Assay 7: OncoPanel testing
Patients at DF/HCC who provided consent to DFCI #11-104, #17-000 or #05-246, or who 
underwent clinical OncoPanel testing, will be identified. OncoPanel will be performed at CAMD 
using DNA extracted from archival FFPE tumor tissue or from a research tumor tissue biopsy. 
Results, including somatic mutations, copy number variations and structural variants, will be 
analyzed and associations with clinical outcomes explored. Integrated analysis of results from 
DNA sequencing (e.g. OncoPanel, WES, WGS, methylation), RNA sequencing (bulk tumor and 
single-cell/single-nuclei) and proteomics (e.g. IHC/IF) assays will also be performed, and 
correlated with clinical outcomes.
9.2.5
Sites Performing Correlative Studies and/or Data Analysis
BWH (Including the Immunology-Oncology Pathology Core, Scott Rodig MD, PhD; Center for 
Advanced Molecular Diagnostics)
Harvard Medical School (Including Peter Sorger PhD, Sandro Santagata MD, PhD)
Dana Farber Cancer Institute (DFCI Center for Immuno-Oncology, DF/HCC Core Blood and 
Tissue Bank, Translational Immunogenomics Lab)
The Broad Institute of MIT
Nanostring Technologies, Inc
Adaptive Biotechnologies

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9.3
Blood Collection
Research blood collection is mandatory for all patients for flow cytometry and potential DNA 
isolation. The samples will be banked in the DF/HCC Core Blood and Tissue Bank and Center for 
Immuno-Oncology  for these and future research purposes. These specimens will become the 
property of the DF/HCC.
The following research blood samples are required: 
Cycle 1 Day 1: 

1 lavender top tube (10 mL) for whole blood

1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
 Every 6 weeks (coinciding with Day 1 of that cycle) for 24 weeks, then every 9 weeks: 

1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
Off Treatment (if progressive disease):

1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
The following research blood samples are optional for patients who come off treatment for a reason 
other than progressive disease:
            Off Treatment (for reason other than progressive disease):

1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
            Follow Up (every 6-12 weeks):

1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
If sample collection is missed at baseline or at the time of progression then the sample should be 
drawn at a future appointment.
For retreatment patients, research blood samples will be drawn every 6 weeks (coinciding with 
Day 1 of that cycle) for 24 weeks, then every 9 weeks. 

1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
For crossover patients, research blood samples will be drawn every 8 weeks (coinciding with Day 
1 of that cycle) for 24 weeks, then every 12 weeks. 

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
1 Streck Tube (10 mL) for whole blood

5 green top tubes (10 mL each) for whole blood
All samples should be de-identified and labeled with the Participant initials, Participant Study ID 
number and date of collection and time point (e.g., “Baseline” or “Cycle X” [X = number of cycle] 
or “Progressive Disease”). If Green top tubes are unavailable, purple top or CPT tubes are 
acceptable substitutions.
Complete a Specimen Requisition Form (17-512 Lab Manual) to be sent with the tubes; make a 
copy of the requisition for the participant’s research chart prior to sending. 

Green Top tubes:
For samples obtained at local sites, these must be processed within 3-4 hrs at ambient 
temperature immediately after being drawn to Mariano Severgnini. For outside institutions, 
samples will either be processed on site for batch shipment at the end of the study or will 
be shipped within 24 hours of collection at ambient temperature overnight to Mariano 
Severgnini:
Center for Immuno-Oncology
Dana-Farber Cancer Institute
440 Brookline Ave-Mayer 308Boston, MA 02215
Phone: (617) 632-2421
Pager: 42093
Processing of samples will be follow the instructions included in the 17-512 Lab Manual.

Streck tubes:
Blood in Streck tubes should be brought/shipped at ambient temperature to the DF/HCC 
Core Blood and Tissue Bank for processing. Please email the DF/HCC Core Blood and 
Tissue Bank with patient name, study ID, date of collection, approximate time of 
collection, and study time point the day prior to collection. 
Core Blood and Tissue Bank
Brigham and Women’s Hospital
Thorn Building – Room 428
20 Shattuck Street
Boston, MA 02215
dfcibreastbank@partners.org

Lavender Top tubes:
Blood in the lavender top (EDTA) tube should be brought/shipped at ambient temperature 
to the DF/HCC Core Blood and Tissue Bank for processing. Please email the DF/HCC 
Core Blood and Tissue Bank with patient name, study ID, date of collection, approximate 
time of collection, and study time point the day prior to collection: 

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Core Blood and Tissue Bank
Brigham and Women’s Hospital
Thorn Building – Room 428
20 Shattuck Street
Boston, MA 02215
dfcibreastbank@partners.org
9.3.1
Immune Markers
Blood will be collected at baseline, every 2 cycles prior to the infusion of study drugs (every 3 
cycles after 24 weeks on study treatment), and at time of progression, for evaluation of immune 
markers. The banked samples will be used to analyze DNA, RNA and protein in future studies.
9.3.1.1
Collection 
Five aliquots of 10 ml of whole blood will be collected in Green Top tubes. The blood sample will 
be collected and processed at baseline, every 2 cycles prior to the infusion of study drugs (every 3 
cycles after 24 weeks on study treatment), and at time of progression for evaluation of immune 
markers. 
9.3.1.2
Potential Testing
Assay 1: Flow cytometry
PBMCs will be generated as described in the 17-512 Lab Manual, and used to assess 
immune cell populations. Surface staining with a panel of antibodies and flow cytometry 
on PBMCs will then be performed as described in Appendices. A selection of the following 
antibodies may be used, and/or additional antibodies, as deemed appropriate and 
informative based on the state of the immune profiling literature at the time of correlative 
science performance: CD8, PD-1, PD-L1, PD-L2, CD4, FOXP3, CD127.
Assay 2: TCR sequencing
PBMCs will be generated as described in the 17-512 Lab Manual, and used to assess 
immune cell populations. DNA will be extracted from PBMCs. Blood specimens may be 
assessed using the most current and informative methodologies at the time that correlative 
science is performed. Potential testing includes use of the immunoSeq assay for high-
throughput sequencing of the CDR3 region of TCR β genes. The distribution of sequencing 
reads over unique TCR β rearrangements can be used to computationally estimate a lower 
bound on the number of unique TCR β rearrangements present in each sample, as 
previously described(120).
9.3.2
Cell-free DNA (cfDNA) analysis
Blood will be collected at baseline, every 6 weeks prior to infusion of study drugs (every 9 weeks 
after 24 weeks on study treatment) and at time of progression, for evaluation of cell-free DNA 

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(cfDNA). The banked samples will be used to analyze DNA, RNA and protein in future studies.
9.3.2.1
Collection of cfDNA specimen(s)
One 10 ml of whole blood will be collected in Streck Tubes. The blood sample will be collected 
and processed at baseline, every 6 weeks prior to infusion of study drugs (every 9 weeks after 24 
weeks on study treatment) and at time of progression. 
9.3.3
Germline Mutational Status
Mutations identified in target genes will be assessed using germline DNA from the baseline blood 
sample. We will assess germline mutational status of clinically actionable genes related to familial 
risks of breast, colon, ovarian, endometrial, pancreatic cancers, as well as melanoma. Genes will 
be analyzed both for single-base changes and large rearrangements by next-generation sequencing. 
Germline mutational profiling will be included as a secondary correlative analysis in this trial to 
explore the activity of carboplatin and nivolumab, compared to carboplatin alone, in patients with 
metastatic TNBC and germline BRCA1/2 mutations.
9.3.3.1
Collection of germline specimen(s)
An additional 10 ml of whole blood will be collected in a lavender top tube at baseline. The blood 
sample will be collected and processed at baseline. Fill the lavender top tube completely and 
immediately mix by gentle inversion 8 to 10 times. Inadequate or delayed mixing may result in 
inaccurate results. The banked samples will be used to analyze DNA, RNA and protein in future 
studies.
9.3.4
Sites Performing Correlatives
DFHCC Core Blood and Tissue Bank
The Broad Institute
DFCI CIO Laboratories
Adaptive Biotechnologies
Foundation Medicine
9.4
Stool Collection 
9.4.1
Collection 
All stool samples will be collected by each patient at home using using a home-based, self-
collection and mail method for stool that has been proven to provide nearly equivalent 
metagenomic and metatranscriptomic data to state-of-the-art fresh-frozen sample-collection 
protocol(121). 
Samples will be collected at the below timepoints:

Baseline

After 3-6 weeks of treatment (any time from C2D1-C3D1 is allowed) 

At time of progression for those patients who achieved response (partial or complete) to 

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treatment

Arm B participants who elect to cross-over to nivolumab + nab-paclitaxel.
Crossover patients will collect samples at the below timepoints:

At time of crossover, prior to initiation of nivolumab + nab-paclitaxel

After 4-8 weeks of crossover treatment (any time from crossover C2D1-C3D1) 

At the time of progression if response observed with nivolumab. 
 Retreatment patients will only collect a sample at the below timepoint: 

At the time of progression after retreatment, if response was again observed 
A patient questionnaire is included in the kits. The questionnaire should be completed at the time 
of stool collection and mailed back along with the sample. Stool samples and questionnaires that 
are not collected at the protocol-specified collection time points will not be protocol violations. 
Crossover and retreatment stool samples are optional. 
9.4.2
Handling and shipping of stool specimens
All kits will be provided to the patients at a clinic visit. Patients will also be provided with a mailer 
in which to return the sample. All samples will be shipped within 24 hours of collection at ambient 
temperature to Brigham and Women’s Hospital/Harvard Cohorts Biorepository, where they will 
be processed and stored (see 17-512 Lab Manual) until batch shipment for analysis. 
9.4.3
Analysis 
We will quantify microbiome features from amplicon, metagenome, metatranscriptome using 
established  pipelines to identify strain-level taxonomic, functional gene, transcriptional, and 
microbially-mediated metabolite profiles associated with patients with mTNBC treated with and 
without nivolumab (see Section 13.7.2).
9.4.4
Sites performing correlative analysis
BWH/Harvard Cohorts Biorepository
Massachusetts General Hospital (Clinical and Translational Epidemiology Unit, Andrew 
Chan MD, MPH)
MicroBiomeDx
9.5
Diet and Physical Activity Assessments
Dietary composition will be assessed through the Block Fat/Sugar/Fruit/Vegetable Screener 
(Appendix C), supplemented with 3 additional questions about fiber intake from the Block 
Vegetable/Fruit/Fiber Screener (Appendix D). The dietary assessment (Appendix C) contains 55 
total questions and takes about 10-12 minutes to complete. Analysis produces estimates of 
saturated fat, trans fat, total sugars, "added sugars" (in sweetened cereals, soft drinks, and sweets), 
fruit and fruit juice, vegetable intake, glycemic load, glycemic index and fiber intake.

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Physical activity patterns will be assessed with the Leisure Score Index of Godin Leisure-Time 
Exercise Questionnaire (LSI).  The LSI is a short instrument which asks participants to quantify 
the number of minutes spent in the last week engaging in vigorous, moderate, and light/mild 
physical activity.  The LSI has undergone extensive reliability and validity testing in a number of 
cancer and general populations(122). We will be using a modified form of the instrument which 
includes not only frequency of activity but also exercise duration.  Weekly minutes of moderate 
and vigorous physical activity will be calculated at each time point using standard scoring 
algorithms. 
Please refer to Appendices C and D for the Diet and Physical Activity Assessments. 
Assessments will be conducted at the below timepoints (in conjunction with collection of stool 
samples):

Baseline

After 3-6 weeks of treatment (any time from C2D1-C3D1 is allowed) 

At time of progression for those patients who achieved response (partial or complete) to 
treatment

Arm B participants who elect to cross-over to nivolumab + nab-paclitaxel.
Crossover patients will complete assessments at the below timepoints:

At time of crossover, prior to initiation of nivolumab + nab-paclitaxel

After 4-8 weeks of crossover treatment (any time from crossover C2D1-C3D1) 

At the time of progression if response observed with nivolumab. 
Retreatment patients will only collect complete an assessment at the below timepoint: 

At the time of progression after retreatment, if response was again observed 
The assessments should be completed at the time of stool collection and mailed back along with 
the sample and stool questionnaire. Diet and physical activity assessments that are not collected at 
the protocol-specified collection time points will not be protocol violations. Crossover and 
retreatment assessments are optional. 
9.6
Central Confirmation of PD-L1 Status
PD-L1 status is prospectively evaluated at the time of enrollment using local institutional 
procedures for testing. Eligibility is determined by local test results. Central confirmation will 
occur retrospectively. Patients in whom a baseline biopsy was not performed need to provide 
archival tissue for performing this central test. 
9.7
 Additional analyses
The above-mentioned analyses may be altered based on novel developments in the field of cancer 
immune profiling at the time of correlative science. Additional markers or alternative technologies 
(based on scientific developments and/or novel technologies) may also be used, to explore 
potential prognostic or predictive candidate markers/panels or markers related to treatment benefit 
and/or safety, to improve diagnostic tests, or to understand breast cancer biology.

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10. STUDY CALENDAR
Screening evaluations are to be conducted within 28 days prior to registration unless otherwise 
specified. Screening assessments occurring within 3 days prior to initiating study treatment do not 
need to be repeated on Cycle 1 Day 1.
As detailed in the Study Calendar, a negative pregnancy test in women of child-bearing potential 
must be documented within 14 days before the first dose of study medication.
In the event that the participant’s condition is deteriorating, laboratory evaluations should be 
repeated within 48 hours prior to initiation of the next cycle of therapy.
Assessments must be performed prior to administration of any study agent. Study assessments and 
agents should be administered within + 4 days of the protocol-specified date, unless otherwise 
noted.
Dose delays of both drugs are allowed per protocol. If Day 1 dosing is delayed, all subsequent 
assessments will be adjusted accordingly. For patients randomized to the experimental arm, if 
drugs are administered on different days in the same 21-day cycle, every effort should be made to 
administer both drugs on the same day in subsequent cycles (all assessments being adjusted 
accordingly), provided that criteria are met per protocol and that 21 ± 4 days have elapsed since 
the administration of the previous dose of carboplatin and 21 ± 4 days since the administration of 
the previous dose of nivolumab.
For crossover and retreatment patients, any baseline assessments (including tumor imaging and 
research samples) should be completed within 14 days of  Day 1 of second course treatment, unless 
stated otherwise. 

107
a.
Medical history includes clinically significant diseases, surgeries, and cancer history (including prior cancer therapies and procedures).
b.
A complete physical examination will be performed at baseline. A limited physical exam will be completed prior to therapy on Day 1 of every cycle 
beginning with Cycle 1.
c.
Vital signs should be collected pre-dose on dosing days and are to include measurements of heart rate, respiratory rate, systolic and diastolic blood 
pressure while the patient is in a seated position, and oral or tympanic temperature.
First Course Treatment Study Calendar
Screening
≤ 4 weeks prior 
to registration
Cycle 1 Day 1
Cycle 2 Day 1
Cycle 3 Day 1
Subsequent 
Cycles Day 1
End of
Treatmentj
Follow-Up
(every 6 months 
+/- 1 month)
Demographics
X
Medical Historya
X
Physical examb, performance 
status
X
X
X
X
X
X
Concurrent medications 
(See Section 5.6) 
X
X
X
X
X
X
Adverse Event assessment
X
X
X
X
X
Xm
Vital signsc
X
X
X
X
X
X
Weightd
X
X
X
X
X
X
Height
X
Hematology panele
X
X
X
X
X
X
Chemistry panelf
X
X
X
X
X
X
TSH/fT4
X
X
X
X
X
X
Coagulation panel (PT/PTT)
X
Pregnancy testg
X
X
X
X
X
Single 12-lead EKG
X
X
Tumor Assessmenth
X
X
Xh
Xk
Xk
Brain MRIi
X
X
Xi
X
X
Research Blood                
(See Section 9.3)
X
X
X
Xn
Xn
Research Biopsy 
(See Section 9.2)
X
X
X
Research Stool Sample  + 
Questionnaires
(See Section 9.4)
Xl
X
Xl
Archival Tumor Retrieval
(See Section 9.1)
X
Survival Assessment
(See Section 5.8)
X

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d.
Weight adjustments for carboplatin will be done according to institutional standards. See Section 5.3.2
e.
Hematology includes: hemoglobin, hematocrit, platelet count, RBC count, WBC count, and percent and absolute differential count.  Results must be 
available prior to the administration of study drug.
f.
Chemistry testing includes: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, calcium, phosphorus, magnesium, total bilirubin, total 
protein, albumin, ALT, AST, alkaline phosphatase, and LDH. Results must be available prior to the administration of study drug.
g.
In female subjects of child-bearing potential as defined in the eligibility criteria, pregnancy test (serum or urine) must be performed within 14 days before 
the first dose of study medication, and on Day 1 of each cycle.
h.
Tumor assessments should consist of 1) CT and/or MRI of the chest/abdomen/pelvis, 2) any other imaging studies as clinically indicated by the treating 
physician. Tumor assessments will be performed at baseline, every 2 cycles/6 weeks for the first 24 weeks with a window of -7 days to + 3 days (e.g., 
between Cycle 2 Day 15 and Cycle 3 Day 4) and then every 3 cycles/9 weeks with a window of -7 days to + 3 days (e.g., between Cycle 11 Day 15 and 
Cycle 12 Day 4). Additional scans are permitted as clinically indicated. All known sites of disease documented at screening should be re-assessed at each 
subsequent tumor evaluation. See Section 11.1.3 Participants who have their treatment held or delayed will continue to have restaging scans that align 
with cycles of treatment received, rather than weeks on study.
i.
Brain MRIs are not mandatory at baseline in patients without history of brain metastases and in whom there are no concerning signs or symptoms. Brain 
MRI should be done with and without contrast. For patients with a history of brain mets, brain MRI is required at baseline and with each restaging; if 
patient received radiation therapy within 6 weeks of registration, then baseline MRI is not needed.  If a participant is unable to have an MRI, a CT of the 
brain with contrast is acceptable.  If  CT with contrast is contraindicated, a CT without contrast is acceptable.
j.
End of treatment visit is to occur 30-45 days from final administration of study treatment.  In the event a participant’s condition is deteriorating or new 
therapy will be initiated within 30 days of the last protocol treatment, end of treatment visit may be performed early (i.e. a window of 15-45 days from 
final administration of study treatment).
k.
For those taken off the treatment for reasons other than progressive disease, tumor measurements should continue to be repeated every 6-12 weeks.
l.
Stool sample may be collected within 4 weeks of starting treatment and 4 weeks from progression, as long as no intervening therapy (otherwise, within 2 
weeks).
m. An adverse event assessment is performed 100 days (-15/+30 days) after the last dose of nivolumab (Arm A and Crossover patients only). This may be 
conducted in person or by phone by the investigator or suitably trained and qualified delegate (e.g. MD, RN, NP, etc). 
n.
Blood samples are mandatory for patients with progressive disease at the end of treatment vist. Blood samples are optional for patients who come 
off treatment for other reasons, at the end of treatment visit and during follow up. Samples during follow up should be drawn every 6-12 weeks, 
alongside tumor assessments, for patients who come off treatment for reasons other than progressive disease.

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a.
Crossover screening assessments may overlap with the most recent first course treatment visit (i.e end of treatment/progression visit). Note: labs should 
occur on C1D1 of crossover therapy (See Section 5.7, Crossover Phase, Criteria to Treat)
b.
A complete physical examination will be performed at baseline. A limited physical exam will be completed prior to therapy on Days 1 and 15 of every 
cycle beginning with Cycle 1.
Crossover Therapy Study Calendar: Nivolumab + nab-Paclitaxel
Cycle 1  Crossover
Cycle 2 Crossover
Cycle 3  Crossover
Subsequent Cycles 
Crossover
Crossover 
Screening
≤ 14 days prior 
to crossover D1a
Day 1
Day 8
Day 15
Day 1
Day 8
Day 15
Day 1
Day 8
Day 15
Day 1
Day 8
Day 15
End of
Crossover 
Treatmentj
Follow-Up
(every 6 
months +/- 
1 month)
Physical examb, 
performance status
X
X
X
X
X
X
X
X
X
X
Concurrent medications 
(See Section 5.6) 
X
X
X
X
X
X
X
X
Adverse Event assessment
X
X
X
X
X
X
X
Xm
Vital signsc
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Weight
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Hematology paneld
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Chemistry panele
X
X
X
X
X
X
X
X
X
X
X
X
X
X
TSH/fT4
X
X
X
X
X
X
Pregnancy testf
X
X
X
X
X
Single 12-lead EKG
Xg
X
Tumor Assessmenth
X
X
Xh
Xk
Xk
Brain MRIi
X
X
Xi
X
X
Research Blood                
(See Section 9.3)
Xn
X
X
Xn
Xn
Mandatory Research Biopsy 
(See Section 9.2)
X
X
X
Research Stool Sample + 
Questionnaires
(See Section 9.4)
Xl
X
Xl
Survival Assessment
(See Section 5.8)
X

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c.
Vital signs should be collected pre-dose on dosing days and are to include measurements of heart rate, respiratory rate, systolic and diastolic blood 
pressure while the patient is in a seated position, and oral or tympanic temperature.
d.
Hematology includes: hemoglobin, hematocrit, platelet count, RBC count, WBC count, and percent and absolute differential count.  Results must be 
available prior to the administration of study drug.
e.
Chemistry testing includes: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, calcium, phosphorus, magnesium, total bilirubin, total 
protein, albumin, ALT, AST, alkaline phosphatase, and LDH. Results must be available prior to the administration of study drug.
f.
In female subjects of child-bearing potential as defined in the eligibility criteria, pregnancy test (serum or urine) must be performed within 7 days before 
the first dose of crossover treatment, and on Day 1 of each cycle.
g.
If EKG performed at the end of treatment visit on First Course Treatment and within 14 days of crossover C1D1, the EKG does not need to be repeated. 
h.
Tumor assessments should consist of 1) CT and/or MRI of the chest/abdomen/pelvis, 2) any other imaging studies as clinically indicated by the treating 
physician. Tumor assessments will be performed at baseline, every 2 cycles/8 weeks for the first 24 weeks with a window of -7 days to + 3 days (e.g., 
between Cycle 2 Day 15 and Cycle 3 Day 4) and then every 3 cycles/12 weeks with a window of -7 days to + 3 days (e.g., between Cycle 11 Day 15 and 
Cycle 12 Day 4). Additional scans are permitted as clinically indicated. If tumor assessments performed at the end of treatment visit on First Course 
Treatment and within 14 days of crossover C1D1, tumor assessments do not need to be repeated during crossover screening.  All known sites of disease 
documented at screening should be re-assessed at each subsequent tumor evaluation. See Section 11.1.3. Participants who have their treatment held or 
delayed will continue to have restaging scans that align with cycles of treatment received, rather than weeks on study.
i.
Brain MRIs are not mandatory during crossover screening in patients without history of brain metastases and in whom there are no concerning signs or 
symptoms. Brain MRI should be done with and without contrast. For patients with a history of brain mets, brain MRI is required at baseline for crossover 
and with each restaging. If a participant is unable to have an MRI, a CT of the brain with contrast is acceptable.  If  CT with contrast is contraindicated, a 
CT without contrast is acceptable.
o.
End of treatment visit is to occur 30-45 days from final administration of crossover study treatment. In the event a participant’s condition is deteriorating 
or new therapy will be initiated within 30 days of the last protocol treatment, end of treatment visit may be performed early (i.e. a window of 15-45 days 
from final administration of crossover study treatment).
j.
For those taken off crossover treatment for reasons other than progressive disease, tumor measurements should continue to be repeated every 6-12 weeks.
k.
Stool sample may be collected within 4 weeks of starting treatment and 4 weeks from progression, as long as no intervening therapy (otherwise, within 2 
weeks).
l.
An adverse event assessment is performed 100 days (-15/+30 days) after the last dose of nivolumab. This may be conducted in person or by phone by the 
investigator or suitably trained and qualified delegate (e.g. MD, RN, NP, etc). 
m. Blood samples are mandatory for crossover patients prior to C1D1 of crossover therapy and for patients with progressive disease at the end of 
crossover treatment visit. For patients who come off crossover treatment for other reasons, blood samples are optional at the end of treatment visit 
and during follow up. Samples during follow up should be drawn every 6-12 weeks, alongside tumor assessments, for patients who come off 
crossover treatment for reasons other than progressive disease.

111
11. MEASUREMENT OF EFFECT
For the purposes of this study, participants should be re-evaluated for response every 2 cycles for 
the first 24 weeks and then every 3 cycles thereafter.
11.1
Antitumor Effect – Solid tumors 
Response and progression in sites of metastases will be evaluated in this study using the 
international criteria proposed by the RECIST 1.1 criteria(1) and immune related response 
criteria(2). Changes in the largest diameter (unidimensional measurement) of the tumor lesions 
and the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria. 
11.1.1 RECIST 1.1 Definitions
Evaluable for Target Disease response. Only those participants who have measurable 
disease present at baseline, have received at least one cycle of therapy, and have had their 
disease re-evaluated will be considered evaluable for target disease response. These 
participants will have their response classified according to the definitions stated below. 
(Note: Participants who exhibit objective disease progression prior to the end of cycle 1 
will also be considered evaluable.)
Evaluable Non-Target Disease Response. Participants who have lesions present at baseline 
that are evaluable but do not meet the definitions of measurable disease, have received at 
least one cycle of therapy, and have had their disease re-evaluated will be considered 
evaluable for non-target disease.  The response assessment is based on the presence, 
absence, or unequivocal progression of the lesions. 
11.1.2 Disease Parameters
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 ≥ 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 might be considered
measurable if the investigator thinks it appropriate to include them.
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, 

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pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, 
abdominal masses (not followed by CT or MRI), and cystic lesions are all considered 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 participant, 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.
11.1.3 Methods for Evaluation of Disease
All measurements should be taken and recorded in metric notation using a ruler, calipers, 
or a digital measurement tool. 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.
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 in diameter as 

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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. 
Chest x-ray. Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung; however, CT is preferable. 
Conventional CT and MRI. This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT thickness is 5mm or less. If CT scans have slice thickness 
greater than 5 mm, the minimum size of 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.
FDG-PET. While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease). New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm:
(a) Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of 
PD based on a new lesion.
(b) No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive 
FDG-PET at follow-up corresponds to a new site of disease confirmed by CT, this is 
PD. If the positive FDG-PET at follow-up is not confirmed as a new site of disease on 
CT, additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not 
PD.
(c)  FDG-PET may be used to upgrade a response to a CR in a manner similar to a 
biopsy in cases where a residual radiographic abnormality is thought to represent 
fibrosis or scarring. The use of FDG-PET in this circumstance should be prospectively 
described in the protocol and supported by disease-specific medical literature for the 
indication. However, it must be acknowledged that both approaches may lead to false 
positive CR due to limitations of FDG-PET and biopsy resolution/sensitivity.

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Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake 
greater than twice that of the surrounding tissue on the attenuation corrected image.
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.
MIBG (meta-iodobenzylguanidine). The following is recommended, to assure high 
quality images are obtained. 
Patient preparation: Iodides, usually SSKI (saturated solution of potassium iodide), are 
administered to reduce thyroidal accumulation of free radioiodine, preferably 
beginning the day prior to injection and continuing for 3 additional days (4 days total). 
For infants and children, one drop t.i.d. is sufficient, for adolescents 2 drops t.i.d., and 
for adults 3 drops t.i.d. Participants and/or parents are asked about exposure to potential 
interfering agents. If none is noted, an indwelling intravenous line is established. The 
dose of MIBG is administered by slow intravenous injection over 90 seconds.
Images from the head to the distal lower extremities should be obtained. 
I-123 MIBG scintigraphy is performed to obtain both planar and tomographic images. 
Planar: Anterior and posterior views from the top of the head to the proximal lower 
extremities are obtained for 10 minutes at 24 hours and occasionally at 48 hours 
following injection of 10 mCi/1.7 square meters of body surface area (~150 μCi/kg, 
maximum 10 mCi). Anterior views of the distal lower extremities are adequate. A large 
field of view dual head gamma camera with low energy collimators is preferred. 
SPECT: Most participants receiving I-123 MIBG also undergo SPECT at 24 hours, 
using a single or multi-headed camera with a low energy collimator. The camera is 
rotated through 360 degrees, 120 projections at 25 seconds per stop. Data are 
reconstructed using filtered back projections with a Butterworth filter and a cut off 
frequency of 0.2-0.5. SPECT/CT may be performed at institutions with this capacity.
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 data 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 from 

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CT, MRI may be used instead of CT in selected instances. 
Endoscopy, Laparoscopy. The utilization of these techniques for objective tumor 
evaluation is not advised. However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint.
Tumor markers. Tumor markers alone cannot be used to assess response. If markers are 
initially above the upper normal limit, they must normalize for a participant to be 
considered in complete clinical response. Specific guidelines for both CA-125 response (in 
recurrent ovarian cancer) and PSA response (in recurrent prostate cancer) have been 
published [JNCI 96:487-488, 2004; J Clin Oncol 17, 3461-3467, 1999; J Clin Oncol 
26:1148-1159, 2008].  In addition, the Gynecologic Cancer Intergroup has developed CA-
125 progression criteria which are to be integrated with objective tumor assessment for use 
in first-line trials in ovarian cancer [JNCI 92:1534-1535, 2000].
Cytology, Histology. These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor 
types, such as germ cell tumors, where known residual benign tumors can remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or 
worsens during treatment when the measurable tumor has met criteria for response or stable 
disease is mandatory to differentiate between response or stable disease (an effusion may 
be a side effect of the treatment) and progressive disease.
11.1.3.1
Evaluation of Target Lesions
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.
11.1.3.2
Evaluation of Non-Target Lesions
Complete Response (CR): Disappearance of all non-target lesions and normalization 

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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).
11.1.3.3
Evaluation of New Lesions
The finding of a new lesion should be unequivocal (i.e. not due to difference in 
scanning technique, imaging modality, or findings thought to represent something other 
than tumor (for example, some ‘new’ bone lesions may be simply healing or flare of 
pre-existing lesions). However, a lesion identified on a follow-up scan in an anatomical 
location that was not scanned at baseline is considered new and will indicate PD. If a 
new lesion is equivocal (because of small size etc.), follow-up evaluation will clarify if 
it truly represents new disease and if PD is confirmed, progression should be declared 
using the date of the initial scan on which the lesion was discovered.
11.1.3.4
Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient's best 
response assignment will depend on the achievement of both measurement and 
confirmation criteria.
For Participants with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Response
Best Overall Response when 
Confirmation is Required*
CR
CR
No
CR
≥ 4 wks Confirmation**
CR
Non-CR/Non-
PD
No
PR
CR
Not evaluated
No
PR
PR
Non-CR/Non-
No
PR
≥ 4 wks Confirmation**

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PD/not 
evaluated
SD
Non-CR/Non-
PD/not 
evaluated
No
SD
Documented at least once ≥ 4 
wks from baseline**
PD
Any
Yes or No
PD
Any
PD***
Yes or No
PD
Any
Any
Yes
PD
No prior SD, PR or CR

See RECIST 1.1 manuscript for further details on what is evidence of a new lesion.
**        Only for non-randomized trials with response as primary endpoint.
***      In exceptional circumstances, unequivocal progression in non-target lesions may be
            accepted as disease progression.
Note:  Participants with a global deterioration of health status requiring discontinuation of 
treatment without objective evidence of disease progression at that time should be 
reported as “symptomatic deterioration.” Every effort should be made to document the 
objective progression even after discontinuation of treatment.
For Participants with Non-Measurable Disease (i.e., Non-Target Disease)
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
Not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD

‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is 
increasingly used as an endpoint for assessment of efficacy in some trials so to assign 
this category when no lesions can be measured is not advised
11.1.4 Duration of Response
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date 
that recurrent or progressive disease is objectively documented (taking as reference for 
progressive disease the smallest measurements recorded since the treatment started, or 
death due to any cause. Participants without events reported are censored at the last disease 
evaluation).
Duration of overall complete response: The duration of overall CR is measured from the 
time measurement criteria are first met for CR until the first date that progressive disease 
is objectively documented, or death due to any cause. Participants without events reported 
are censored at the last disease evaluation.

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Duration of stable disease: Stable disease is measured from the start of the treatment until 
the criteria for progression are met, taking as reference the smallest measurements recorded 
since the treatment started, including the baseline measurements. 
11.1.5 Time to Response
Time to objective response: The time to objective response is defined as the time from 
randomization to the date of the first documented CR or PR (whichever is first recorded).
11.1.6 Clinical Benefit Rate 
Clinical Benefit Rate: Clinical Benefit Rate (CBR) is defined as CR, PR and stable disease 
(SD) for ≥  24 weeks.
11.1.7 Survival
Overall Survival: Overall Survival (OS) is defined as the time from randomization (or 
registration) to death due to any cause, or censored at date last known alive.
Progression-Free Survival: Progression-Free Survival (PFS) is defined as the time from 
randomization (or registration) to the earlier of progression or death due to any cause. 
Participants alive without disease progression are censored at date of last disease 
evaluation.
Time to Progression: Time to Progression (TTP) is defined as the time from 
randomization (or registration) to progression, or censored at date of last disease 
evaluation for those without progression reported.
11.1.8 Response Review
Central Review will be conducted by the DF/HCC Tumor Imaging Metric Core for 
DF/HCC Institutions.
11.2
Other Response Parameters
11.2.1 Definition of Tumor Response Using Immune-Related Response Criteria (irRC)
The sum of the longest diameter of lesions (SPD) at tumor assessment using the immune-
related response criteria (irRC) for progressive disease incorporate the contribution of new 
measurable lesions. Each net Percentage Change in Tumor Burden per assessment using 
irRC criteria accounts for the size and growth kinetics of both old and new lesions as they 
appear.
11.2.1.1
Impact of New Lesions on irRC

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New lesions themselves do not qualify as progressive disease. However, their contribution 
to total tumor burden is included in the SPD which in turn feeds into the irRC criteria for 
tumor response. Therefore, new non-measurable lesions will not discontinue any subject 
from the study.
11.2.1.2
Definition of Target Lesions Response Using irRC

irComplete Response (irCR): Complete disappearance of all target lesions. This category 
encompasses exactly the same subjects as “CR” by the mWHO criteria.

irPartial Response (irPR): Decrease, relative to baseline, or 50% or greater in the sum of 
the products of the two largest perpendicular diameters of all target and all new measurable 
target lesions (i.e., Percentage Change in Tumor Burden). Note: the appearance of new 
measurable lesions is factored into the overall tumor burden, but does not automatically 
qualify as progressive disease until the SBD increases by ≥ 25% when compared to SPD 
at nadir.

irStable Disease (irSD): Does not meet criteria for irRC or irPR, in the absence of 
progressive disease.

irProgressive Disease (irPD): At least 25% increase Percentage Change in Tumor Burden 
(i.e. taking SPD of all target lesions and any new lesions) when compared to SPD at nadir.
11.2.1.3
Definition of Non-Target Lesions Response Using irRC

irComplete Response (irCR): Complete disappearance of all non-target lesions. This 
category encompasses exactly the same subjects as “CR” by the mWHO criteria.

irPartial Response (irPR) or irStable Disease (irSD): Non-target lesion(s) are not 
considered in the definition of PR; these terms do not apply.

irProgressive Disease (irPD): Increases in number or size of non-target lesion(s) does not 
constitute progressive disease unless/until the Percentage Change in Tumor Burden 
increases by 25% (i.e. the SPD at nadir of the target lesions increases by the required 
amount).
11.2.1.4
Definition of Overall Response Using irRC
Overall response using irRC will be based on these criteria:

Immune-Related Complete Response (irCR): Complete disappearance of all tumor 
lesions (target an non-target) together with no new measurable/unmeasurable lesions for at 
least 4 weeks from the date of documentation of complete response.

Immune-Related Partial Response (irPR): The sum of the products of the two largest 
perpendicular diameters of all target lesions is measured and captured as the SPD baseline.  
At each subsequent tumor assessment, the SPD of the two largest perpendicular diameters 
of all target lesions and of new measurable lesions are added together to provide the 
Immune Response Sum of Product Diameters (irSPD). A decrease, relative to baseline, of 
the irSPD compared to the previously SPD baseline of 50% or greater is considered an 
irPR.

Immune-Related Stable Disease (irSD): irSD is defined as the failure to meet criteria for 

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immune complete response or immune partial response, in the absence of progressive 
disease

Immune-Related Progressive Disease (irPD): It is recommended in difficult cases to 
confirm PD by serial imaging. Any of the following will constitute PD:

At least 25% increase in the SPD of all target lesions over baseline SPD calculated for 
the target lesions.

At least 25% increase in the SPD of all target lesions and new measurable lesions 
(irSPD) over the baseline SPD calculated for the target lesions.
Criteria for determining overall response by irRC are summarized as follows:
11.2.1.5
Immune-Related Best Overall Response Using irRC (irBOR)
irBOR is the best confirmed overall response over the study as a whole, recorded between 
the date of first dose until the last tumor assessment before subsequent therapy (except for 
local palliative radiotherapy for painful bone lesions) for the individual subject in the study. 
For the assessment of irBOR, all available assessments per subject are considered.
irCR or irPR determinations included in the irBOR assessment must be confirmed by a 
second (confirmatory) evaluation meeting the criteria for response and performed no less 
than 4 weeks after the criteria for response are first met.
12. DATA REPORTING / REGULATORY REQUIREMENTS
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements).

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12.1
Data Reporting
12.1.1 Method
The Office of Data Quality (ODQ) will collect, manage, and perform quality checks on the 
data for this study.
12.1.2 Responsibility for Data Submission
Investigative sites within DF/HCC or DF/PCC are responsible for submitting data and/or 
data forms to the Office of Data Quality in accordance with DF/HCC SOPs.
12.2
Data Safety Monitoring
The DF/HCC Data and Safety Monitoring Board (DSMB) will review and monitor study progress, 
toxicity, safety and other data from this study. The board is chaired by a medical oncologist from 
outside of DF/HCC and has external and internal representation. Information that raises any 
questions about participant safety or protocol performance will be addressed by the Overall PI, 
statistician and study team. Should any major concerns arise, the DSMB will offer 
recommendations regarding whether or not to suspend the study.
The DSMB will meet twice a year to review accrual, toxicity, response and reporting information. 
Information to be provided to the DSMB may include: participant accrual; treatment regimen 
information; adverse events and serious adverse events reported by category; summary of any 
deaths on study; audit results; and a summary provided by the study team. Other information (e.g. 
scans, laboratory values) will be provided upon request. 
12.3
Multicenter Guidelines
This protocol will adhere to the policies and requirements of the DF/HCC Multi-Center Data and 
Safety Monitoring Plan. The specific responsibilities of the Overall PI, Coordinating Center, and 
Participating Institutions and the procedures for auditing are presented in Appendix B.

The Overall PI/Coordinating Center is responsible for distributing all IND Action Letters 
or Safety Reports to all participating institutions for submission to their individual IRBs 
for action as required.

Mechanisms will be in place to ensure quality assurance, protocol compliance, and adverse 
event reporting at each site.

Except in very unusual circumstances, each participating institution will order the study 
agent(s) directly from supplier. A participating site may order the agent(s) only after the 
initial IRB approval for the site has been forwarded to the Coordinating Center.
12.4
Collaborative Research and Future Use of Data and Samples
Tissue, blood, stool, bodily fluids, and other materials derived from these will be collected in this 

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study to analyze genes, DNA, RNA, proteins and cells for the study’s correlative endpoints and 
potential future research, utilizing new types of biomarker testing as it becomes available. 
These samples and any data generated as a part of these clinical trials may be used for future 
research studies and may be provided to collaborating investigators both within and outside of the 
DF/HCC for either correlative endpoints or secondary use. Samples and data may be shared with 
outside non-profit academic investigators, as well as with for-profit pharmaceutical investigators 
or commercial entitites, with whom we collaborate. When samples or data are sent to collaborators 
and when any research is performed on them, all information will be identified with a code, and 
will not contain any PHI, such as name, birthday, or MRNs. 
In order to  allow the greatest amount of research to be performed on the specimens and 
information generated as a part of this trial, researchers in this study may share results of genetic 
sequencing with other scientists. De-identified specimen or genetic data may be placed into one of 
more publicly-accessible scientific databases, such as the National Institutes of Health’s Database 
for Genotypes and Phenotypes (dbGaP). The results from the correlative research on this study 
will be shared with these public databases. Through such databases, researchers from around the 
world will have access to de-identified samples or data for future research. More detailed 
information, beyond the public database, may only be accessed by scientists at other research 
centers who have received special permission to review de-identified data.
13. STATISTICAL CONSIDERATIONS 
13.1
Study Design/Endpoints
This is an open-label, multi-institutional, randomized phase 2 study of carboplatin at AUC 6 
intravenously every 3 weeks, with or without nivolumab 360 mg intravenously every 3 weeks, in 
subjects with metastatic triple-negative breast cancer previously treated with 0 prior lines of 
therapy in the metastatic setting. The target enrollment is 132 first-line patients; 66 per arm of 
treatment.
 
The primary endpoint is to compare in the intent-to-treat study population the progression-free 
survival (PFS) of carboplatin in combination with nivolumab versus carboplatin alone, in patients 
with previously untreated metastatic TNBC. PFS is defined according to RECIST 1.1 criteria 
(Section 11.1).
Secondary endpoints include:

Overall response rate (ORR) according to RECIST 1.1 (Section 11.1) and immune-related 
response criteria (irRC) (Section 11.2)

Overall survival (OS)

Clinical benefit rate (CBR) according to RECIST 1.1, defined as CR, PR or stable disease 
for ≥  24 weeks

Duration of response (DOR) and time to objective response (TTOR)

Toxicity graded according to NCI CTCAE, Version 4.0

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The above endpoints will be assessed in the following study populations:
-Intent-to-treat
-PD-L1-positive
-Germline BRCA1 or BRCA2 mutation carriers
-Crossover to nab-paclitaxel plus nivolumab after progression on carboplatin alone
13.2
Sample Size, Accrual Rate and Study Duration
Based on data of recent trials in a similar population of patients with TNBC treated with 
carboplatin, a median PFS of 3 months would be expected with carboplatin in monotherapy(30, 
31). We anticipate that achieving a PFS of at least 5 months for combination therapy (Arm A) in 
the present study would make the regimen worthy of further investigation. Considering a one-
sided 0.05 type-I error and 85% power to detect a 2-month absolute difference in median PFS at 
the time of final analysis (hazard ratio = 0.6), 132 first-line patients would need to be enrolled on 
the trial.
The final analysis will occur when 115 PFS events are observed, or 9 months after the last patient 
is randomized, whichever occurs first. An interim analysis for futility will occur when 50% 
information is obtained (57 PFS events). The study would stop early if the observed HR from a 
Cox model >1.0 (Arm A: Arm B). It is estimated that the interim analysis will occur approximately 
21 months after the first patient is randomized.
The expected accrual rate is 5-6 patients per month and, considering an estimated enrollment of 
40 first-line patients prior to activation of the study amendment to first-line metastatic setting only, 
accrual of 132 first-line patients is anticipated to be completed at 18 months from activation of the 
crossover amendment. The expected study duration to primary analysis of PFS is 40 months from 
study activation.
13.3
Stratification Factors for Secondary Analyses
Considering the differences in clinical activity with carboplatin reported in the TNT trial for 
patients who carry a germline BRCA1 or BRCA2 mutation(31), compared to those without a known 
BRCA mutation, germline BRCA status (mutation vs. wild-type/unknown) will be a stratification 
factor.
Platinum therapy in the neo-/adjuvant setting may preclude resistance to carboplatin upon 
rechallenge or inability to maintain dose and/or duration of carboplatin due to toxicity. Thus, prior 
exposure to platinum will be a stratification factor.
In order to avoid a potential selection bias based on PD-L1 status, PD-L1-negative status is 
restricted to a maximum of 60% of patients randomized on the trial. PD-L1 status will be a 
stratification factor. In IMpassion130, 40% of patients were found to be PDL1-positive. When 
restricting PDL1-negative status to 60% of patients enrolled on DFCI 17-512, assuming 40% of 
PDL1-positive patients (n=48/120) and similar distribution between treatment arms (n=24 per 
arm), there would be 52% power to demonstrate an improvement in median PFS corresponding to 
HR 0.60 in the PDL1-positive group.

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13.4
Interim Monitoring Plan
We will perform a safety run-in analysis in the first 12 patients randomized to the experimental 
arm. If there are 4 or more dose-limiting toxicity (DLTs) in the first 12 patients included, 
enrollment will be halted to discuss whether the study will be amended, with re-evaluation of the 
appropriate dosing schedule and study design, or closed. Section 5.4 describes the DLT 
definitions used in this current study, which will be assessed in the first cycle (21 days of cycle 
1). In the case that enrollment continues, these first 12 patients will be included in the efficacy 
analysis. 
Additionally, we will perform a safety run-in analysis in the first 12 participants who crossover to 
nivolumab + nab-paclitaxel. If there are 4 or more dose-limiting toxicity (DLTs) in the first 12 
participants treated with nivolumab + nab-paclitaxel, crossover will be halted to discuss whether 
the study will be amended, with re-evaluation of the appropriate crossover dosing schedule and 
design, or the option to crossover closed. Section 5.4 describes the DLT definitions used in this 
current study, which will be assessed in the first cycle of crossover treatment (28 days of cycle 1 
crossover). In the case that crossover treatment with nivolumab + nab-paclitaxel continues, these 
first 12 patients will be included in the efficacy analysis.
An additional interim analysis for futility will occur when 50% information is obtained (after 57 
PFS events have occurred). The study would stop early if the Z-statistic from a stratified logrank 
test is less than 0 (corresponding to an observed HR > 1.0 under a stratified Cox model). It is 
estimated that the interim analysis will occur at approximately 21 months from study activation.
13.5
Analysis of Primary Endpoint
The primary objective is to compare the median PFS achieved with the experimental combination 
of carboplatin plus nivolumab versus carboplatin alone, and this will be assessed among all first-
line patients who initiated protocol therapy according to the randomized treatment assignment.
PFS is defined as the time from study randomization to disease progression according to RECIST 
1.1, medical judgment or death due to any cause, whichever occurred first. Patients alive without 
disease progression are censored at the date of last disease evaluation. Definitive analysis of the 
efficacy data will be performed when 115 PFS events are recorded and will be based on the intent-
to-treat principle where all patients will be analyzed as randomized. 
The primary comparison in PFS between the two treatment arms will be performed by the stratified 
log-rank test with prior exposure to platinum (yes or no), germline BRCA status (mutation or wild-
type/unknown), and PD-L1 status (positive or negative). Factor(s) will be dropped from the 
stratified logrank test if an insufficient number of patients/events allow the model to converge. The 
test will be one-sided with a significance level at 0.05. 
The Kaplan-Meier estimates will also be calculated separately for patients allocated to each 
treatment regimen. Multivariable Cox proportional hazards models will be used to estimate 
treatment efficacy in PFS with adjusting for potential confounders such as age at study entry, stage 

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(locally advanced or metastatic), BRCA mutation status (positive, negative or unknown), prior 
exposure to platinum (yes or no) and PD-L1 status (positive or negative). Potential interactions 
between treatment and clinical factors and biomarkers, including BRCA mutation, will be explored 
in the Cox models. Model diagnostics will be performed to check whether the proportionality 
assumption is valid in those models. Should it fail, appropriate analysis, such as models with time-
dependent effects, will be explored. An exploratory subset analysis in the eligible-only population 
will also be performed, and results of this analysis will be compared with those from the intent-to-
treat population in the primary analysis. Any substantial difference will be carefully examined.
13.6
Analysis of Secondary Endpoints
Efficacy Endpoints 
All patients who initiated protocol therapy will also be evaluated for ORR (according to RECIST 
1.1 and irRC), for CBR, DOR, TTOR and OS. 
Radiographic response will be assessed using RECIST 1.1 criteria and irRC, as defined in section 
11. Objective response will require confirmatory scans as indicated. The ORR (CR + PR), 
according to RECIST 1.1 and irRC, will be reported with 95% exact confidence intervals. Clinical 
benefit is defined as CR, PR or SD ≥ 24 weeks according to RECIST 1.1. CBR will be reported 
with 95% exact confidence intervals. Median DOR and TTOR will be reported with ranges. 
Overall survival will be reported with Kaplan Meier estimates. 
For OS, the stratified log-rank test will be one-sided with significance level 0.05. Treatment 
efficacy in these secondary endpoints will be assessed by Cox models adjusting for clinical factors 
such as age at study entry, stage (locally advanced or metastatic), BRCA mutation status (positive, 
negative or unknown), prior exposure to platinum (yes or no) and PD-L1 status (positive or 
negative) Specifically, treatment efficacy, including PFS and these secondary endpoints, will be 
assessed in patients with known germline BRCA mutation. Dichotomous endpoints of response 
will be compared using Cochran-Maentel-Haenszel chi-squared tests with significance level 0.05. 
Safety and tolerability 
All patients will be evaluable for toxicity from the time of their first treatment with any study 
agent. Toxicity will be graded according to NCI CTCAE, Version 4.0. Toxicities will be 
summarized by maximum grade and by treatment arm.  Incidence rate of each toxicity will be 
reported with 95% exact confidence intervals. The incidence rates of any grade 3 or higher toxicity 
will be compared across arms using a two-sided Fisher’s exact test.
13.7
Correlative endpoints
13.7.1 Tumor biopsies and TIL assessment 
Previous studies have demonstrated that, in addition to direct cytotoxic effects, chemotherapy-
induced cell death can be immunogenic, causing T cell tumor infiltration and sensitizing tumors 
to immune checkpoint blockade(123). Cytotoxic CD8+ T cell infiltration has been reported to 
increase after treatment with carboplatin across different tumor types(124-126). Recently, Herbst 
et al. have demonstrated that patients who presented an increase of at least 5% in expression of 

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PD-L1 in tumor microenvironment experienced a bigger likelihood to respond to treatment with 
the anti-PD-L1 atezolizumab(99). Also, modifications in molecular signature of tumor 
microenvironment also correlated with response rate to this drug.
Tumor-infiltrating lymphocytes (TILs) by histological assessment will be quantitative and 
evaluated as a percentage of cells stained (0-100%). Data from Loi and colleagues suggest that the 
mean number of TILs in first-line metastatic TNBC is likely similar to that observed in first-line 
metastatic HER2-positive samples from the CLEOPATRA study(127). Thus, the median TIL 
value was 10%, with a mean number of TILs of 17% (standard deviation as a continuous variable 
= 21%). TILs will be analyzed as a continuous variable using descriptive statistics to summarize 
the distribution observed among study participants.
A) To assess the relationship between baseline TILs and progression-free survival, we plan to 
perform a mandatory research biopsy of a safely accesible tumor lesion at baseline.  The 
association of TILs and PFS will be evaluated in a proportional hazards regression model using 
non-linear cubic spline functions knotted at evenly spaced quintiles and covariates for the 
treatment effect and study stratification factors(128). Linear and non-linear components of the 
model will be assessed using Wald-type tests. If a non-linear association is detected, the point 
estimate and 95% prediction bands will be reported for the log relative hazard over the entire 
distribution of TILs. If no significant non-linear effects are observed, the step-down model will 
evaluate the the linear multivariate proportional hazards regression model and report adjust hazard 
ratio and 95% confidence interval for a linear increase in TILs. In addition, modification of a 
treatment effect will be explored as an interaction test, and if non-significant (two-sided alpha = 
0.05) the step-down model with main effects will be reported. Assuming a 10% assay failure rate 
(n = 60 evaluable per arm) and variability in TILs as report by Loi and colleagues, there will be 
92%  power to detect a linear main effect in the nivolumab-containing arm which corresponds to 
a hazard ratio of 0.8 for every 10% difference in TILs(129). Power calculations were performed 
using the powerSurvEpi package in R v3.1.1.
B) To assess the absolute change in the percentage of TILs before and after starting treatment, a 
mandatory biopsy at 3-6 weeks post-treatment (any time between C2D1 and C3D1) is required, if 
tumor is safely accessible. This on-treatment biopsy will be performed in, at least, the first 36 
patients with accessible disease in each arm. Assuming the drop-out/non-evaluable rate will be 
10%, 32 paired samples will be available. Descriptive statistics will be used to summarize the 
distribution of TILs observed at baseline and after 3-6 weeks of therapy (e.g. mean, standard 
deviation, median, and inter-quartile range). The evaluation of change in TILs within each arm 
will be based on a Wilcoxon signed rank test (absolute difference) using a one-sided alpha = 0.1 
for each arm. Based on variability of TILs reported by Loi and colleagues in paired specimens 
before and after treatment with chemotherapy for TNBC, with 32 evaluable paired specimens 
anticipated per arm, there will be an 80% power to detect an increase in TILs from 22.3% to 30.9%, 
under an assumption of an additive shift model with a Gaussian common density function.
Table of Target Effects with Different Sample Sizes per Arm
N required biopsy 
(per arm)
Drop-out/non-
evaluable rate
N evaluable (per arm)
∆ TILs
32
10%
28
9.2 

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34
10%
30
8.9 
36
10%
32
8.6
If paired biopsies at baseline and at 3-6 weeks after treatment are obtained in 59 paired samples in 
each arm (assuming a drop-out/non-evaluable rate of 10% in the entire study population), there 
will be statistical power to detect the following change in TILs between both study arms. Assuming 
that the change in TILs from pre-treatment to 3-6 weeks after starting protocol therapy is 38% (∆ 
TILs = 8.6) in Arm A (Carboplatin+Nivolumab) and 20% (∆ TILs = 4.5) in Arm B (Carboplatin 
alone), with a standard deviation of 8, using a Wilcoxon-Mann-Whitney test with one-sided alpha 
of 0.1, the study has 91% power to detect the difference of change in TILs between Arm A 
(Carboplatin+Nivolumab) and Arm B (Carboplatin alone).
C) For secondary correlative endpoints to characterize the expression of tumor markers by 
immunohistochemistry (IHC) and/or immunofluorescence (IF), descriptive statistics and 
agglomerative hierarchical clustering techniques will be used to summarize the distribution and 
patterns of profiles observed in baseline samples. Tests of association with clinical outcomes (PFS, 
OS, and response) will be exploratory using Cox proportional hazard and logistic regression 
models, respective, and inferences will use Benjaminin-Hochberg step-up tests to control the false 
discovery rate with multiplex assays, and any positive findings will require validation in future 
studies with independent samples for unbiased estimates of the degress of association with 
treatment effects and clinical outcomes. 
Optional repeat biopsies will be performed at time of progression, to explore changes in TILs and 
other tissue markers. Descriptive statistics will be used to summarize the change in TILs, and 
inferences on treatment-effects will use non-parametric tests (e.g. Wilcoxon rank sum) with two-
sided alpha 0.05.  The association of changes in TILs with clinical outcomes of PFS and OS will 
be exploratory and hypothesis generating in the subset of patients with evaluable repeat biopsies. 
Analysis plans will consider using Cox models with time-varying covariates to account for the 
post-baseline assessments.
D) Single-cell/single-nuclei RNA sequencing will be performed on biopsies at baseline, on 
treatment, and, when available, at progression for a subset of first-line therapy patients, and a 
subset of patients who elect to crossover to nab-paclitaxel plus nivolumab, enrolled at DFCI to 
assess the relationship of timepoint-specific tumor and immune cell subpopulations with clinical 
outcomes in exploratory analyses. In addition, changes in single-cell/single-nuclei RNA 
expression signatures from baseline will be correlated with response. Standard preprocessing and 
quality control algorithms will be performed to filter out low quality cells and to normalize the 
expression data. Differentially expressed genes will be identified using the Benjamini-Hochberg 
procedure to control the false discovery rate for multiple comparisons. Descriptive statistics and 
clustering techniques, including principal component analysis and t-distributed stochastic 
neighbor embedding, will be employed to summarize the distributions of the expression data and 
identify tumor and immune cell subpopulations. Changes in cell subpopulations between 
baseline, on-treatment, and at progression biopsies will be assessed with Wilcoxon signed-rank 
tests, while differences in cell subpopulations between responders and non-responders will be 
compared with Mann-Whitney tests. Preliminary associations of tumor and immune cell 

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subpopulations with progression-free and overall survival will be explored using Cox 
proportional hazard models. 
13.7.2 Analysis of intestinal microbiome
Overall, we plan to describe the landscape of gut microbiota in patients with mTNBC, and the 
changes in their gut microbiota after two cycles of treatment and, if available, at time of 
progression. Statistical analyses of intestinal microbiota samples will be performed using R 
Statistical Language (v3.1.1) and GraphPad Prism (version 6.0e) software packages. Unpaired 
Wilcoxon rank sum test (two-tailed) will be used for comparisons of continuous variables between 
two groups. Bar plots will be used to represent the data’s mean at the center values, with error bars 
to indicate standard deviation.  Diversity of gut microbiota will be estimated by Shannon index. In 
order to explore the association of response (objective response according RECIST 1.1 and 
progression-free survival) to baseline microbiota diversity, and changes from baseline in 
microbiota, inference will be based on Wilcoxon rank sum tests and estimates of predictive value 
along the continuous scales will be visualized using receiver operating characteristic (ROC) curves 
and reported with c-index and confidence intervals derived from variance estimates of Somers 
rank correlation.
We will quantify microbiome features from amplicon, metagenome, metatranscriptome using 
established  pipelines to identify strain-level taxonomic, functional gene, transcriptional, and 
microbially-mediated metabolite profiles associated with patients with mTNBC, treated with and 
without nivolumab. We will use modified multivariate linear modeling to identify statistically 
significant features associated with outcomes. Statistical tests for association with these outcomes 
and covariates will be performed using the sparse generalized linear model MaAsLin, which 
provides random effects models for both log-Gaussian and zero-inflated negative binomial link 
functions. Computational workflows for these steps are implemented as AnADAMA2 
(http://huttenhower.sph.harvard.edu/anadama) 
workflows, 
a 
reproducible 
data 
handling 
environment that captures all provenance during the analysis process.
To assess the relationships between α-diversity and physical activity, dietary components, or BMI, 
we will divide the diversity measures into tertiles or at the median and compare the clinical 
characteristics according to the resulting diversity classes.  
13.8
Reporting and Exclusions
13.8.1 Evaluation of Efficacy
For this Phase II trial, the efficacy evaluable population is a modified intent-to-treat (ITT) 
population. The modified ITT population consists of all patients who initiate protocol 
therapy, even if there are major protocol therapy deviations. 
For the primary endpoint of this trial, patients with previously untreated metastatic TNBC 
who initiate protocol therapy (as first-line therapy in the metastatic setting), enrolled prior 
or post-crossover amendment, will be included. An exploratory efficacy evaluation will be 
conducted in all second-line patients who initiate protocol therapy (second-line carboplatin 
plus nivolumab prior to crossover amendment and second-line nab-paclitaxel plus 

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nivolumab after crossover amendment).
13.8.2 Evaluation of Safety
The safety population will be used in the safety data summaries. The safety population 
consists of all patients who took at least one dose of any randomized treatment and who 
have at least one post-baseline safety assessment. Note that a patient who had no adverse 
events constitutes a safety assessment. Patients who have received at least one dose of 
study drug but have no post-treatment safety data of any kind would be excluded.
14. PUBLICATION PLAN
The results should be made public within 1 year of reaching the end of the study. The end of the 
study is the time point at which the last data items are to be reported, or after the outcome data are 
sufficiently mature for analysis, as defined in the section on Sample Size, Accrual Rate and Study 
Duration. If a report is planned to be published in a peer-reviewed journal, then that initial release 
may be an abstract that meets the requirements of the International Committee of Medical Journal 
Editors. A full report of the outcomes should be made public no later than three (3) years after the 
end of the study.

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15. REFERENCES
1.
Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. New 
response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). European 
journal of cancer (Oxford, England : 1990). 2009;45(2):228-47.
2.
Wolchok JD, Hoos A, O'Day S, Weber JS, Hamid O, Lebbe C, et al. Guidelines for 
the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clin 
Cancer Res. 2009;15(23):7412-20.
3.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA: a cancer journal for 
clinicians. 2016;66(1):7-30.
4.
Perou CM. Molecular Stratification of Triple-Negative Breast Cancers. The 
Oncologist. 2010;15(Supplement 5):39-48.
5.
O'Brien KM, Cole SR, Tse CK, Perou CM, Carey LA, Foulkes WD, et al. Intrinsic 
breast tumor subtypes, race, and long-term survival in the Carolina Breast Cancer Study. Clinical 
cancer research : an official journal of the American Association for Cancer Research. 
2010;16(24):6100-10.
6.
Liedtke C, Mazouni C, Hess KR, Andre F, Tordai A, Mejia JA, et al. Response to 
neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin 
Oncol. 2008;26(8):1275-81.
7.
Ono M, Tsuda H, Shimizu C, Yamamoto S, Shibata T, Yamamoto H, et al. Tumor-
infiltrating lymphocytes are correlated with response to neoadjuvant chemotherapy in triple-
negative breast cancer. Breast Cancer Res Treat. 2012;132(3):793-805.
8.
Liu S, Lachapelle J, Leung S, Gao D, Foulkes WD, Nielsen TO. CD8+ lymphocyte 
infiltration is an independent favorable prognostic indicator in basal-like breast cancer. Breast 
Cancer Res. 2012;14(2):R48.
9.
Andre F, Zielinski CC. Optimal strategies for the treatment of metastatic triple-
negative breast cancer with currently approved agents. Annals of Oncology. 2012;23(suppl 
6):vi46-vi51.
10.
Sparano JA, Makhson AN, Semiglazov VF, Tjulandin SA, Balashova OI, 
Bondarenko IN, et al. Pegylated Liposomal Doxorubicin Plus Docetaxel Significantly Improves 
Time to Progression Without Additive Cardiotoxicity Compared With Docetaxel Monotherapy 
in Patients With Advanced Breast Cancer Previously Treated With Neoadjuvant-Adjuvant 
Anthracycline Therapy: Results From a Randomized Phase III Study. Journal of Clinical 
Oncology. 2009;27(27):4522-9.
11.
Dear RF, McGeechan K, Jenkins MC, Barratt A, Tattersall MH, Wilcken N. 
Combination versus sequential single agent chemotherapy for metastatic breast cancer. Cochrane 
Database Syst Rev. 2013(12):CD008792.
12.
Sledge GW, Neuberg D, Bernardo P, Ingle JN, Martino S, Rowinsky EK, et al. Phase 
III trial of doxorubicin, paclitaxel, and the combination of doxorubicin and paclitaxel as front-
line chemotherapy for metastatic breast cancer: an intergroup trial (E1193). J Clin Oncol. 
2003;21(4):588-92.
13.
Gennari A, Stockler M, Puntoni M, Sormani M, Nanni O, Amadori D, et al. Duration 

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
131
of chemotherapy for metastatic breast cancer: a systematic review and meta-analysis of 
randomized clinical trials. J Clin Oncol. 2011;29(16):2144-9.
14.
Gopalakrishnan V, Spencer CN, Nezi L, Reuben A, Andrews MC, Karpinets TV, et 
al. Gut microbiome modulates response to anti-PD-1 immunotherapy in melanoma patients. 
Science. 2018;359(6371):97-103.
15.
Kaufman PA, Awada A, Twelves C, Yelle L, Perez EA, Velikova G, et al. Phase III 
open-label randomized study of eribulin mesylate versus capecitabine in patients with locally 
advanced or metastatic breast cancer previously treated with an anthracycline and a taxane. J 
Clin Oncol. 2015;33(6):594-601.
16.
Robert NJ, Dieras V, Glaspy J, Brufsky AM, Bondarenko I, Lipatov ON, et al. 
RIBBON-1: randomized, double-blind, placebo-controlled, phase III trial of chemotherapy with 
or without bevacizumab for first-line treatment of human epidermal growth factor receptor 2-
negative, locally recurrent or metastatic breast cancer. J Clin Oncol. 2011;29(10):1252-60.
17.
Gray R, Bhattacharya S, Bowden C, Miller K, Comis RL. Independent review of 
E2100: a phase III trial of bevacizumab plus paclitaxel versus paclitaxel in women with 
metastatic breast cancer. J Clin Oncol. 2009;27(30):4966-72.
18.
Burstein HJ, Elias AD, Rugo HS, Cobleigh MA, Wolff AC, Eisenberg PD, et al. 
Phase II study of sunitinib malate, an oral multitargeted tyrosine kinase inhibitor, in patients with 
metastatic breast cancer previously treated with an anthracycline and a taxane. J Clin Oncol. 
2008;26(11):1810-6.
19.
Baselga J, Gomez P, Greil R, Braga S, Climent MA, Wardley AM, et al. Randomized 
phase II study of the anti-epidermal growth factor receptor monoclonal antibody cetuximab with 
cisplatin versus cisplatin alone in patients with metastatic triple-negative breast cancer. J Clin 
Oncol. 2013;31(20):2586-92.
20.
Stemmler HJ, diGioia D, Freier W, Tessen HW, Gitsch G, Jonat W, et al. 
Randomised phase II trial of gemcitabine plus vinorelbine vs gemcitabine plus cisplatin vs 
gemcitabine plus capecitabine in patients with pretreated metastatic breast cancer. British Journal 
of Cancer. 2011;104(7):1071-8.
21.
Fountzilas G, Athanassiadis A, Kalogera-Fountzila A, Aravantinos G, Bafaloukos D, 
Briasoulis E, et al. Paclitaxel by 3-h infusion and carboplatin in anthracycline-resistant advanced 
breast cancer. A phase II study conducted by the Hellenic Cooperative Oncology Group. Eur J 
Cancer. 1997;33(11):1893-5.
22.
Perez EA, Hillman DW, Stella PJ, Krook JE, Hartmann LC, Fitch TR, et al. A phase 
II study of paclitaxel plus carboplatin as first-line chemotherapy for women with metastatic 
breast carcinoma. Cancer. 2000;88(1):124-31.
23.
Loesch D, Robert N, Asmar L, Gregurich MA, O'Rourke M, Dakhil S, et al. Phase II 
multicenter trial of a weekly paclitaxel and carboplatin regimen in patients with advanced breast 
cancer. J Clin Oncol. 2002;20(18):3857-64.
24.
Fountzilas G, Kalofonos HP, Dafni U, Papadimitriou C, Bafaloukos D, Papakostas P, 
et al. Paclitaxel and epirubicin versus paclitaxel and carboplatin as first-line chemotherapy in 
patients with advanced breast cancer: a phase III study conducted by the Hellenic Cooperative 
Oncology Group. Ann Oncol. 2004;15(10):1517-26.
25.
Fountzilas G, Dafni U, Dimopoulos MA, Koutras A, Skarlos D, Papakostas P, et al. A 
randomized phase III study comparing three anthracycline-free taxane-based regimens, as first 
line chemotherapy, in metastatic breast cancer: a Hellenic Cooperative Oncology Group study. 
Breast Cancer Res Treat. 2009;115(1):87-99.

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
132
26.
Loesch D, Asmar L, McIntyre K, Doane L, Monticelli M, Paul D, et al. Phase II trial 
of gemcitabine/carboplatin (plus trastuzumab in HER2-positive disease) in patients with 
metastatic breast cancer. Clin Breast Cancer. 2008;8(2):178-86.
27.
Maisano R, Zavettieri M, Azzarello D, Raffaele M, Maisano M, Bottari M, et al. 
Carboplatin and gemcitabine combination in metastatic triple-negative anthracycline- and 
taxane-pretreated breast cancer patients: a phase II study. J Chemother. 2011;23(1):40-3.
28.
O'Shaughnessy J, Osborne C, Pippen JE, Yoffe M, Patt D, Rocha C, et al. Iniparib 
plus chemotherapy in metastatic triple-negative breast cancer. N Engl J Med. 2011;364(3):205-
14.
29.
Byrski T, Huzarski T, Dent R, Gronwald J, Zuziak D, Cybulski C, et al. Response to 
neoadjuvant therapy with cisplatin in BRCA1-positive breast cancer patients. Breast Cancer Res 
Treat. 2009;115(2):359-63.
30.
Isakoff SJ, Mayer EL, He L, Traina TA, Carey LA, Krag KJ, et al. TBCRC009: A 
Multicenter Phase II Clinical Trial of Platinum Monotherapy With Biomarker Assessment in 
Metastatic Triple-Negative Breast Cancer. J Clin Oncol. 2015;33(17):1902-9.
31.
Tutt A, Ellis P, Kilburn L, Gilett C, Pinder S, Abraham J, et al. Abstract S3-01: The 
TNT trial: A randomized phase III trial of carboplatin (C) compared with docetaxel (D) for 
patients with metastatic or recurrent locally advanced triple negative or BRCA1/2 breast cancer 
(CRUK/07/012). Cancer Research. 2015;75(9 Supplement):S3-01-S3-.
32.
Schreiber RD, Old LJ, Smyth MJ. Cancer Immunoediting : Integrating Suppression 
and Promotion. (i).
33.
Schreiber RD. Cancer Immunoediting : Integrating Suppression and Promotion. 
2012;1565(2011).
34.
Mlecnik B, Bindea G, Angell HK, Berger A, Lagorce C, Lugli A, et al. Towards the 
introduction of the ‘ Immunoscore ’. 2014:199-209.
35.
Tosolini M, Camus M, Berger A, Wind P, Lagorce-page C. References and Notes 1. 
2006;313(September):1960-5.
36.
Denkert C, von Minckwitz G, Brase JC, Sinn BV, Gade S, Kronenwett R, et al. 
Tumor-Infiltrating Lymphocytes and Response to Neoadjuvant Chemotherapy With or Without 
Carboplatin in Human Epidermal Growth Factor Receptor 2-Positive and Triple-Negative 
Primary Breast Cancers. Journal of Clinical Oncology. 2015;33(9):983-91.
37.
Adams S, Gray RJ, Demaria S, Goldstein L, Perez Ea, Shulman LN, et al. Prognostic 
Value of Tumor-Infiltrating Lymphocytes in Triple-Negative Breast Cancers From Two Phase 
III Randomized Adjuvant Breast Cancer Trials: ECOG 2197 and ECOG 1199. Journal of 
Clinical Oncology. 2014;32(27):JCO.2013.55.0491--JCO.2013.55.0491-.
38.
Pedoeem A, Azoulay-Alfaguter I, Strazza M, Silverman GJ, Mor A. Programmed 
death-1 pathway in cancer and autoimmunity. Clin Immunol. 2014;153(1):145-52.
39.
Zhang X, Schwartz JC, Guo X, Bhatia S, Cao E, Lorenz M, et al. Structural and 
functional analysis of the costimulatory receptor programmed death-1. Immunity. 
2004;20(3):337-47.
40.
Lazar-Molnar E, Yan Q, Cao E, Ramagopal U, Nathenson SG, Almo SC. Crystal 
structure of the complex between programmed death-1 (PD-1) and its ligand PD-L2. Proc Natl 
Acad Sci U S A. 2008;105(30):10483-8.
41.
Lin DY, Tanaka Y, Iwasaki M, Gittis AG, Su HP, Mikami B, et al. The PD-1/PD-L1 
complex resembles the antigen-binding Fv domains of antibodies and T cell receptors. Proc Natl 
Acad Sci U S A. 2008;105(8):3011-6.

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
133
42.
Cheng X, Veverka V, Radhakrishnan A, Waters LC, Muskett FW, Morgan SH, et al. 
Structure and interactions of the human programmed cell death 1 receptor. J Biol Chem. 
2013;288(17):11771-85.
43.
Sheppard KA, Fitz LJ, Lee JM, Benander C, George JA, Wooters J, et al. PD-1 
inhibits T-cell receptor induced phosphorylation of the ZAP70/CD3zeta signalosome and 
downstream signaling to PKCtheta. FEBS Lett. 2004;574(1-3):37-41.
44.
Ott PA, Hodi FS, Robert C. CTLA-4 and PD-1/PD-L1 blockade: new 
immunotherapeutic modalities with durable clinical benefit in melanoma patients. Clin Cancer 
Res. 2013;19(19):5300-9.
45.
Yao S, Chen L. PD-1 as an immune modulatory receptor. Cancer J. 2014;20(4):262-
4.
46.
Nishimura H, Agata Y, Kawasaki A, Sato M, Imamura S, Minato N, et al. 
Developmentally regulated expression of the PD-1 protein on the surface of double-negative 
(CD4-CD8-) thymocytes. Int Immunol. 1996;8(5):773-80.
47.
Huang X, Venet F, Wang YL, Lepape A, Yuan Z, Chen Y, et al. PD-1 expression by 
macrophages plays a pathologic role in altering microbial clearance and the innate inflammatory 
response to sepsis. Proc Natl Acad Sci U S A. 2009;106(15):6303-8.
48.
Pena-Cruz V, McDonough SM, Diaz-Griffero F, Crum CP, Carrasco RD, Freeman 
GJ. PD-1 on immature and PD-1 ligands on migratory human Langerhans cells regulate antigen-
presenting cell activity. J Invest Dermatol. 2010;130(9):2222-30.
49.
Keir ME, Butte MJ, Freeman GJ, Sharpe AH. PD-1 and its ligands in tolerance and 
immunity. Annu Rev Immunol. 2008;26:677-704.
50.
Karim R, Jordanova ES, Piersma SJ, Kenter GG, Chen L, Boer JM, et al. Tumor-
expressed B7-H1 and B7-DC in relation to PD-1+ T-cell infiltration and survival of patients with 
cervical carcinoma. Clin Cancer Res. 2009;15(20):6341-7.
51.
Taube JM, Anders RA, Young GD, Xu H, Sharma R, McMiller TL, et al. 
Colocalization of inflammatory response with B7-h1 expression in human melanocytic lesions 
supports an adaptive resistance mechanism of immune escape. Sci Transl Med. 
2012;4(127):127ra37.
52.
Sanmamed MF, Chen L. Inducible expression of B7-H1 (PD-L1) and its selective 
role in tumor site immune modulation. Cancer J. 2014;20(4):256-61.
53.
Topalian SL, Drake CG, Pardoll DM. Targeting the PD-1/B7-H1(PD-L1) pathway to 
activate anti-tumor immunity. Curr Opin Immunol. 2012;24(2):207-12.
54.
Kroemer G, Senovilla L, Galluzzi L, André F, Zitvogel L. review Natural and 
therapy-induced immunosurveillance in breast cancer. Nature Publishing Group. 
2015;21(10):1128-38.
55.
Denkert C, Loibl S, Noske A, Roller M, Muller BM, Komor M, et al. Tumor-
associated lymphocytes as an independent predictor of response to neoadjuvant chemotherapy in 
breast cancer. J Clin Oncol. 2010;28(1):105-13.
56.
Denkert C, von Minckwitz G, Brase JC, Sinn BV, Gade S, Kronenwett R, et al. 
Tumor-infiltrating lymphocytes and response to neoadjuvant chemotherapy with or without 
carboplatin in human epidermal growth factor receptor 2-positive and triple-negative primary 
breast cancers. J Clin Oncol. 2015;33(9):983-91.
57.
Loi S, Sirtaine N, Piette F, Salgado R, Viale G, Van Eenoo F, et al. Prognostic and 
predictive value of tumor-infiltrating lymphocytes in a phase III randomized adjuvant breast 
cancer trial in node-positive breast cancer comparing the addition of docetaxel to doxorubicin 

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
134
with doxorubicin-based chemotherapy: BIG 02-98. Journal of Clinical Oncology. 
2013;31(7):860-7.
58.
Dushyanthen S, Beavis PA, Savas P, Teo ZL, Zhou C, Mansour M, et al. Relevance 
of tumor-infiltrating lymphocytes in breast cancer. BMC Medicine. 2015;1:1-13.
59.
Gatalica Z, Snyder C, Maney T, Ghazalpour A, Holterman DA, Xiao N, et al. 
Programmed cell death 1 (PD-1) and its ligand (PD-L1) in common cancers and their correlation 
with molecular cancer type. Cancer Epidemiol Biomarkers Prev. 2014;23(12):2965-70.
60.
Emens L, Adams S, Loi S, Schmid P, Schneeweiss A, Rugo H, et al. Abstract OT1-
01-06: A phase III randomized trial of atezolizumab in combination with nab-paclitaxel as first 
line therapy for patients with metastatic triple-negative breast cancer (mTNBC). Cancer 
Research. 2016;76(4 Supplement):OT1-01-6.
61.
Emens LA, Braiteh FS, Cassier P, DeLord J-P, Eder JP, Shen X, et al. Abstract PD1-
6: Inhibition of PD-L1 by MPDL3280A leads to clinical activity in patients with metastatic 
triple-negative breast cancer. Cancer Research. 2015;75(9 Supplement):PD1-6.
62.
Nanda R, Chow LQM, Dees EC, Berger R, Gupta S, Geva R, et al. Pembrolizumab in 
Patients With Advanced Triple-Negative Breast Cancer: Phase Ib KEYNOTE-012 Study. 
Journal of Clinical Oncology. 2016;34(21):2460-7.
63.
Dirix L, Takacs I, Nikolinakos P, Jerusalem G, Arkenau H-T, Hamilton E, et al. 
Abstract S1-04: Avelumab (MSB0010718C), an anti-PD-L1 antibody, in patients with locally 
advanced or metastatic breast cancer: A phase Ib JAVELIN solid tumor trial. Cancer Research. 
2016;76(4 Supplement):S1-04-S1-.
64.
Schmid P, Adams S, Rugo HS, Schneeweiss A, Barrios CH, Iwata H, et al. 
Atezolizumab and Nab-Paclitaxel in Advanced Triple-Negative Breast Cancer. N Engl J Med. 
2018;379(22):2108-21.
65.
Administration FaD. Nivolumab (Opdivo): Highlights of Prescribing Information 
http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/125527s000lbl.pdf2015 [
66.
Nishino M, Giobbie-Hurder A, Hatabu H, Ramaiya NH, Hodi FS. Incidence of 
Programmed Cell Death 1 Inhibitor-Related Pneumonitis in Patients With Advanced Cancer: A 
Systematic Review and Meta-analysis. JAMA Oncol. 2016;2(12):1607-16.
67.
Kok M, Voorwerk L, Horlings H, Sikorska K, van der Vijver K, Slagter M, et al. 
Adaptive phase II randomized trial of nivolumab after induction treatment in triple negative 
breast cancer (TONIC trial): Final response data stage I and first translational data. Journal of 
Clinical Oncology. 2018;36(15_suppl):1012-.
68.
Kelland L. The resurgence of platinum-based cancer chemotherapy. Nat Rev Cancer. 
2007;7(8):573-84.
69.
Pardoll DM. The blockade of immune checkpoints in cancer immunotherapy. Nature 
reviews Cancer. 2012;12(4):252-64.
70.
Brahmer JR, Tykodi SS, Chow LQ, Hwu WJ, Topalian SL, Hwu P, et al. Safety and 
activity of anti-PD-L1 antibody in patients with advanced cancer. N Engl J Med. 
2012;366(26):2455-65.
71.
Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC, McDermott DF, et al. 
Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. N Engl J Med. 
2012;366(26):2443-54.
72.
Topalian SL, Drake CG, Pardoll DM. Immune checkpoint blockade: a common 
denominator approach to cancer therapy. Cancer Cell. 2015;27(4):450-61.
73.
Savas P, Salgado R, Denkert C, Sotiriou C, Darcy PK, Smyth MJ, et al. Clinical 

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
135
relevance of host immunity in breast cancer: from TILs to the clinic. Nature reviews Clinical 
oncology. 2015.
74.
Carbognin L, Pilotto S, Nortilli R, Brunelli M, Nottegar A, Sperduti I, et al. 
Predictive and Prognostic Role of Tumor-Infiltrating Lymphocytes for Early Breast Cancer 
According to Disease Subtypes: Sensitivity Analysis of Randomized Trials in Adjuvant and 
Neoadjuvant Setting. Oncologist. 2016;21(3):283-91.
75.
Dieci MV, Criscitiello C, Goubar A, Viale G, Conte P, Guarneri V, et al. Prognostic 
value of tumor-infiltrating lymphocytes on residual disease after primary chemotherapy for 
triple-negative breast cancer: a retrospective multicenter study. Ann Oncol. 2015;26(7):1518.
76.
Gatalica Z, Snyder C, Maney T, Ghazalpour a, Holterman Da, Xiao N, et al. 
Programmed Cell Death 1 (PD-1) and Its Ligand (PD-L1) in Common Cancers and Their 
Correlation with Molecular Cancer Type. Cancer Epidemiology Biomarkers & Prevention. 
2014;23(12):2965-70.
77.
Chen DS, Mellman I. Oncology meets immunology: The cancer-immunity cycle. 
Immunity. 2013;39(1):1-10.
78.
Adams S, Diamond JR, Hamilton EP, Pohlmann PR, Tolaney SM, Molinero L, et al., 
editors. Phase Ib trial of atezolizumab in combination with nab-paclitaxel in patients with 
metastatic triple-negative breast cancer (mTNBC). 2016 American Society of Clinical Oncology 
(ASCO) Annual Meeting; 2016; Chicago, IL (USA): J Clin Oncol 34, 2016 (suppl; abstr 1009).
79.
Bracci L, Schiavoni G, Sistigu A, Belardelli F. Immune-based mechanisms of 
cytotoxic chemotherapy: implications for the design of novel and rationale-based combined 
treatments against cancer. Cell death and differentiation. 2014;21(1):15-25.
80.
Hato SV, Khong A, de Vries IJ, Lesterhuis WJ. Molecular pathways: the 
immunogenic effects of platinum-based chemotherapeutics. Clinical cancer research : an official 
journal of the American Association for Cancer Research. 2014;20(11):2831-7.
81.
Tutt A, Ellis P, Kilburn L, Gilett C, Pinder S, Abraham J, et al. TNT: A randomized 
phase III trial of carboplatin (C) compared with docetaxel (D) for patients with metastatic or 
recurrent locally advanced triple negative or BRCA1/2 breast cancer. San Antonio Breast Cancer 
Symposium. 2014:Abstr S3-01.
82.
Bhattacharyya A, Ear US, Koller BH, Weichselbaum RR, Bishop DK. The breast 
cancer susceptibility gene BRCA1 is required for subnuclear assembly of Rad51 and survival 
following treatment with the DNA cross-linking agent cisplatin. The Journal of biological 
chemistry. 2000;275(31):23899-903.
83.
Le DT, Uram JN, Wang H, Bartlett BR, Kemberling H, Eyring AD, et al. PD-1 
Blockade in Tumors with Mismatch-Repair Deficiency. The New England journal of medicine. 
2015;372(26):2509-20.
84.
Rizvi NA, Hellmann MD, Brahmer JR, Juergens RA, Borghaei H, Gettinger S, et al. 
Nivolumab in Combination With Platinum-Based Doublet Chemotherapy for First-Line 
Treatment of Advanced Non-Small-Cell Lung Cancer. J Clin Oncol. 2016;34(25):2969-79.
85.
Brahmer JR, Drake CG, Wollner I, Powderly JD, Picus J, Sharfman WH, 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. J Clin Oncol. 
2010;28(19):3167-75.
86.
Kanda S, Goto K, Shiraishi H, Kubo E, Tanaka A, Utsumi H, et al. Safety and 
efficacy of nivolumab and standard chemotherapy drug combination in patients with advanced 
non-small-cell lung cancer: a four arms phase Ib study. Ann Oncol. 2016;27(12):2242-50.

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
136
87.
Long GV, Tykodi SS, Schneider JG, Garbe C, Gravis G, Rashford M, et al. 
Assessment of nivolumab exposure and clinical safety of 480 mg every 4 weeks flat-dosing 
schedule in patients with cancer. Ann Oncol. 2018;29(11):2208-13.
88.
Wainberg ZA, Hochster HS, Kim EJ-H, George B, Kalyan A, Chiorean EG, et al. 
Phase I study of nivolumab (Nivo) + nab-paclitaxel (nab-P) + gemcitabine (Gem) in advanced 
pancreatic cancer (APC). Journal of Clinical Oncology. 2019;37(4_suppl):298-.
89.
Goldman JW, Waterhouse D, George B, O'Dwyer P, Chen T, Trunova N, et al. 
P1.03-026 Interim Results of a Phase I Study of Nivolumab plus Nab-Paclitaxel/Carboplatin in 
Patients with NSCLC. Journal of Thoracic Oncology. 2017;12(11):S1960-S1.
90.
Sharma P, Allison JP. The future of immune checkpoint therapy. 2015;348(6230).
91.
Smith DC, McDermott DF, Powderly JD, Carvajal RD, Sosman JA, Atkins MB, et al. 
new england journal. 2012:2443-54.
92.
Hwu W-j, Ph D, Topalian SL, Hwu P, Chen S, Ph D, et al. Safety and Activity of 
Anti–PD-L1 Antibody in Patients with Advanced Cancer. 2012:2455-65.
93.
Gajewski TF. The Next Hurdle in Cancer Immunotherapy_ Overcoming the Non–T-
Cell–Inflamed Tumor Microenvironment. Seminars in Oncology. 2015;42(4):663-71.
94.
Ribas A. Adaptive Immune Resistance : How Cancer Protects from Immune Attack. 
2015(September):915-20.
95.
Perez EA, Thompson EA, Ballman KV, Anderson SK, Asmann YW. Genomic 
Analysis Reveals That Immune Function Genes Are Strongly Linked to Clinical Outcome in the 
North Central Cancer Treatment Group N9831 Adjuvant Trastuzumab Trial. 2015;33(7).
96.
Salgado R, Denkert C, Demaria S, Sirtaine N, Klauschen F, Pruneri G, et al. The 
evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an 
International TILs Working Group 2014. Annals of Oncology. 2014;26(2):259-71.
97.
Ali HR, Provenzano E, Dawson S, Blows FM, Liu B, Shah M, et al. Association 
between CD8 + T-cell in fi ltration and breast cancer survival in 12 439 patients. 
2014(June):1536-43.
98.
Denkert C, Loibl S, Noske A, Roller M, Mu BM, Komor M, et al. J OURNAL OF C 
LINICAL O NCOLOGY Tumor-Associated Lymphocytes As an Independent Predictor of 
Response to Neoadjuvant Chemotherapy in Breast Cancer. 2015;28(1):105-14.
99.
Herbst RS, Soria J-c, Kowanetz M, Fine GD, Hamid O, Gordon MS, et al. antibody 
MPDL3280A in cancer patients. Nature. 2014;515(7528):563-7.
100.
Trinchieri G. Cancer Immunity: Lessons From Infectious Diseases. J Infect Dis. 
2015;212 Suppl 1:S67-73.
101.
Human Microbiome Project C. Structure, function and diversity of the healthy human 
microbiome. Nature. 2012;486(7402):207-14.
102.
Qin J, Li R, Raes J, Arumugam M, Burgdorf KS, Manichanh C, et al. A human gut 
microbial gene catalogue established by metagenomic sequencing. Nature. 2010;464(7285):59-
65.
103.
Roy S, Trinchieri G. Microbiota: a key orchestrator of cancer therapy. Nat Rev 
Cancer. 2017.
104.
Sivan A, Corrales L, Hubert N, Williams JB, Aquino-Michaels K, Earley ZM, et al. 
Commensal Bifidobacterium promotes antitumor immunity and facilitates anti-PD-L1 efficacy. 
Science. 2015;350(6264):1084-9.
105.
Vetizou M, Pitt JM, Daillere R, Lepage P, Waldschmitt N, Flament C, et al. 
Anticancer immunotherapy by CTLA-4 blockade relies on the gut microbiota. Science. 

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
137
2015;350(6264):1079-84.
106.
Goedert JJ, Jones G, Hua X, Xu X, Yu G, Flores R, et al. Investigation of the 
association between the fecal microbiota and breast cancer in postmenopausal women: a 
population-based case-control pilot study. J Natl Cancer Inst. 2015;107(8).
107.
Liu K, Lu C. Gut microbes modulate host response to immune checkpoint inhibitor 
cancer immunotherapy. Transl Cancer Res. 2018;7(Suppl 5):S608-S10.
108.
Matson V, Fessler J, Bao R, Chongsuwat T, Zha Y, Alegre ML, et al. The commensal 
microbiome is associated with anti-PD-1 efficacy in metastatic melanoma patients. Science. 
2018;359(6371):104-8.
109.
Routy B, Le Chatelier E, Derosa L, Duong CPM, Alou MT, Daillere R, et al. Gut 
microbiome influences efficacy of PD-1-based immunotherapy against epithelial tumors. 
Science. 2018;359(6371):91-7.
110.
Alvarez-Mercado AI, Navarro-Oliveros M, Robles-Sanchez C, Plaza-Diaz J, Saez-
Lara MJ, Munoz-Quezada S, et al. Microbial Population Changes and Their Relationship with 
Human Health and Disease. Microorganisms. 2019;7(3).
111.
Fayfman M, Flint K, Srinivasan S. Obesity, Motility, Diet, and Intestinal Microbiota-
Connecting the Dots. Curr Gastroenterol Rep. 2019;21(4):15.
112.
Ticinesi A, Lauretani F, Tana C, Nouvenne A, Ridolo E, Meschi T. Exercise and 
immune system as modulators of intestinal microbiome: implications for the gut-muscle axis 
hypothesis. Exerc Immunol Rev. 2019;25:84-95.
113.
Gopalakrishnan V, C S, J M, al e, editors. The gut microbiome of metastatic 
melanoma patients initiating systemic therapy is influenced by host factors including diet, 
probiotic and antiobotic use. Society for Immunotherapy of Cancer; 2018; Washington, DC.
114.
Salgado R, Denkert C, Demaria S, Sirtaine N, Klauschen F, Pruneri G, et al. The 
evaluation of tumor-infiltrating lymphocytes (TILs) in breast cancer: recommendations by an 
International TILs Working Group 2014. Ann Oncol. 2015;26(2):259-71.
115.
Chen BJ, Chapuy B, Ouyang J, Sun HH, Roemer MG, Xu ML, et al. PD-L1 
expression is characteristic of a subset of aggressive B-cell lymphomas and virus-associated 
malignancies. Clinical cancer research : an official journal of the American Association for 
Cancer Research. 2013;19(13):3462-73.
116.
Shi M, Roemer MG, Chapuy B, Liao X, Sun H, Pinkus GS, et al. Expression of 
programmed cell death 1 ligand 2 (PD-L2) is a distinguishing feature of primary mediastinal 
(thymic) large B-cell lymphoma and associated with PDCD1LG2 copy gain. The American 
journal of surgical pathology. 2014;38(12):1715-23.
117.
Parker JS, Mullins M, Cheang MC, Leung S, Voduc D, Vickery T, et al. Supervised 
risk predictor of breast cancer based on intrinsic subtypes. J Clin Oncol. 2009;27(8):1160-7.
118.
Prat A, Parker JS, Karginova O, Fan C, Livasy C, Herschkowitz JI, et al. Phenotypic 
and molecular characterization of the claudin-low intrinsic subtype of breast cancer. Breast 
Cancer Res. 2010;12(5):R68.
119.
Riaz N, Havel JJ, Makarov V, Desrichard A, Urba WJ, Sims JS, et al. Tumor and 
Microenvironment Evolution during Immunotherapy with Nivolumab. Cell. 2017;171(4):934-49 
e16.
120.
Robins HS, Campregher PV, Srivastava SK, Wacher A, Turtle CJ, Kahsai O, et al. 
Comprehensive assessment of T-cell receptor beta-chain diversity in alphabeta T cells. Blood. 
2009;114(19):4099-107.
121.
Franzosa EA, Morgan XC, Segata N, Waldron L, Reyes J, Earl AM, et al. Relating 

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
138
the metatranscriptome and metagenome of the human gut. Proceedings of the National Academy 
of Sciences of the United States of America. 2014;111(22):E2329-38.
122.
Jacobs D, Ainsworth B, Hartman T, Leon A. A simultaneous evaluation of 10 
commonly used physical activity questionnaires. Medicine & Science in Sports & Exercise. 
1993;25:81-91.
123.
Pfirschke C, Engblom C, Rickelt S, Cortez-Retamozo V, Garris C, Pucci F, et al. 
Immunogenic Chemotherapy Sensitizes Tumors to Checkpoint Blockade Therapy. Immunity. 
2016;44(2):343-54.
124.
Hodge JW, Garnett CT, Farsaci B, Palena C, Tsang KY, Ferrone S, et al. 
Chemotherapy-induced immunogenic modulation of tumor cells enhances killing by cytotoxic T 
lymphocytes and is distinct from immunogenic cell death. Int J Cancer. 2013;133(3):624-36.
125.
Giaccone G, Camidge DR, Liu SV, Powderly JD, Hodi FS, Gettinger S, et al., editors. 
Safety, activity and biomarkers of atezolizumab (MPDL3280A) with platinum-based 
chemotherapy (chemo) in non-small cell lung cancer (NSCLC): A Phase Ib study. European 
Cancer Congress 2015; 2015 Sept 25-29, 2015; Vienna, Austria: Abstr 513.
126.
Peng J, Hamanishi J, Matsumura N, Abiko K, Murat K, Baba T, et al. Chemotherapy 
Induces Programmed Cell Death-Ligand 1 Overexpression via the Nuclear Factor-kappaB to 
Foster an Immunosuppressive Tumor Microenvironment in Ovarian Cancer. Cancer Res. 
2015;75(23):5034-45.
127.
Luen SJ, Salgado R, Fox S, Savas P, Eng-Wong J, Clark E, et al. Tumour-infiltrating 
lymphocytes in advanced HER2-positive breast cancer treated with pertuzumab or placebo in 
addition to trastuzumab and docetaxel: a retrospective analysis of the CLEOPATRA study. 
Lancet Oncol. 2017;18(1):52-62.
128.
Harrell FE. Regression modeling strategies: R package version 3.6-3 http://CRAN.R-
project.org/package=rms2013 [
129.
Hsieh FY, Lavori PW. Sample-size calculations for the Cox proportional hazards 
regression model with nonbinary covariates. Control Clin Trials. 2000;21(6):552-60.

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APPENDIX A
PERFORMANCE STATUS CRITERIA
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Description
100
Normal, no complaints, no evidence 
of disease.
0
Normal activity.  Fully active, able 
to carry on all pre-disease 
performance without restriction.
90
Able to carry on normal activity; 
minor signs or symptoms of disease.
80
Normal activity with effort; some 
signs or symptoms of disease.
1
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work).
70
Cares for self, unable to carry on 
normal activity or to do active work.
60
Requires occasional assistance, but 
is able to care for most of his/her 
needs.
2
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and about 
more than 50% of waking hours.
50
Requires considerable assistance and 
frequent medical care.
40
Disabled, requires special care and 
assistance.
3
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours.
30
Severely disabled, hospitalization 
indicated.  Death not imminent.
20
Very sick, hospitalization indicated. 
Death not imminent.
4
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair.
10
Moribund, fatal processes 
progressing rapidly.
5
Dead.
0
Dead.

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APPENDIX B
MULTI-CENTER DATA AND SAFETY MONITORING PLAN
Dana-Farber/Harvard Cancer Center
Multi-Center Data and Safety Monitoring Plan

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TABLE OF CONTENTS
1. INTRODUCTION
1.1 Purpose
1.2 Multi-Center Data and Safety Monitoring Plan Definitions
2. GENERAL ROLES AND RESPONSIBILITIES
2.1 DF/HCC Sponsor
2.2 Coordinating Center 
2.3 Participating Institution
3.   DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS
3.1 Protocol Distribution
3.2 Protocol Revisions and Closures
3.3 Informed Consent Requirements
3.4 IRB Documentation
3.5 IRB Re-Approval
3.6 Participant Confidentiality and Authorization Statement
3.7 DF/HCC Multi-Center Protocol Registration Policy
3.8 DF/HCC Protocol Case Number
3.9 Safety Assessments and Toxicity Monitoring
3.10 Data Management
4. REQUISITIONING INVESTIGATIONAL DRUG
5. MONITORING: QUALITY CONTROL
5.1 Ongoing Monitoring of Protocol Compliance
5.2 Monitoring Reports
5.3 Accrual Monitoring
6. AUDITING: QUALITY ASSURANCE
6.1 Audit Plan: DF/HCC Sponsored Trials
6.2 Audit Notification
6.3 Audit Reports 
6.4 Participating Institution Performance

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1.     INTRODUCTION
The Dana-Farber/Harvard Cancer Center Multi-Center Data and Safety Monitoring Plan 
(DF/HCC DSMP) outlines the procedures for conducting a DF/HCC Multi-Center research 
protocol. The DF/HCC DSMP should serve as a reference for any sites external to DF/HCC that 
will be participating in the research protocol.
1.1  
Purpose
To establish standards that will ensure that a Dana-Farber/Harvard Cancer Center Multi-Center 
protocol will comply with Federal Regulations, Health Insurance Portability and Accountability 
Act (HIPAA) requirements and applicable DF/HCC Standard Operating Procedures.       
1.2  
Multi-Center Data and Safety Monitoring Plan Definitions
DF/HCC Multi-Center Protocol:  A research protocol in which one  or more outside 
institutions are collaborating with Dana-Farber/Harvard Cancer Center where  a DF/HCC 
investigator is the sponsor. DF/HCC includes Dana-Farber/Partners Cancer Care (DF/PCC) 
Network Clinical Trial Affiliates. 
Lead Institution:  Dana-Farber Cancer Institute (DFCI) is responsible for the coordination, 
development, submission, and approval of a protocol as well as its subsequent amendments per 
the DFCI IRB and applicable regulatory guidelines (Food and Drug Administration (FDA) etc.).  
The Lead Institution is typically the home of the DF/HCC Sponsor. The Lead Institution also 
typically serves as the Coordinating Center for the DF/HCC Multi-Center Protocol.  
DF/HCC Sponsor:  The person sponsoring the submitted Multi-Center protocol.  Within 
DF/HCC, this person is the Overall Principal Investigator who takes responsibility for initiation, 
management and conduct of the protocol at all research locations. In applicable protocols, the 
DF/HCC Sponsor will serve as the single liaison with any regulatory agencies (i.e. FDA, etc.). 
The DF/HCC Sponsor has ultimate authority over the protocol and is responsible for the conduct 
of the study at DF/HCC and all Participating Institutions. In most cases the DF/HCC Sponsor is 
the same person as the DF/HCC Overall Principal Investigator; however, both roles can be filled 
by two different people. 
Participating Institution: An institution that is outside the DF/HCC and DF/PCC consortium 
that is collaborating with DF/HCC on a protocol where the sponsor is a DF/HCC Investigator.  
The Participating Institution acknowledges the DF/HCC Sponsor as having the ultimate authority 
and responsibility for the overall conduct of the study.   
Coordinating Center:  The entity (i.e. Lead Institution or Project Manager) that provides 
administrative support to the DF/HCC Sponsor in order that he/she may fulfill the 
responsibilities outlined in the protocol document and DSMP, and as specified in applicable 
regulatory guidelines. In general, the Lead Institution is the Coordinating Center for the DF/HCC 
Multi-Center Protocol. 

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DF/HCC Office of Data Quality (ODQ): A group within DF/HCC responsible for ensuring 
high-quality standards are used for data collection and the ongoing management of clinical trials, 
auditing, and data and safety monitoring. ODQ also coordinates quality assurance efforts related 
to multi-center clinical research.
DF/HCC Clinical Trials Research Informatics Office (CTRIO): A group within DF/HCC 
responsible for providing a comprehensive data management platform for managing clinical trial 
data.
2.    GENERAL ROLES AND RESPONSIBILITIES
For DF/HCC Multi-Center Protocols, the DF/HCC Sponsor, the Coordinating Center, and the 
Participating Institutions are expected to adhere to the following general responsibilities: 
2.1  
DF/HCC Sponsor
The DF/HCC Sponsor, 
, will accept responsibility for all aspects of 
conducting a DF/HCC Multi-Center protocol which includes but is not limited to: 

Oversee the coordination, development, submission, and approval of the protocol as well 
as subsequent amendments. 

Ensure that the investigators, study team members, and Participating Institutions are 
qualified and appropriately resourced to conduct the protocol.  

Include the Multi-Center Data and Safety Monitoring Plan as an appendix to the protocol.

Ensure all Participating Institutions are using the correct version of the protocol.

Ensure that each participating investigator and study team member receives adequate 
protocol training and/or a Site Initiation Visit prior to enrolling participants and 
throughout trial’s conduct as needed.

Ensure the protocol will be provided to each participating site in a language 
understandable to all applicable site personnel when English is not the primary language. 

Monitor progress and overall conduct of the study at all Participating Institutions. 

Ensure all DFCI Institutional Review Board (IRB), DF/HCC and other applicable (i.e. 
FDA) reporting requirements are met. 

Review data and maintain timely submission of data for study analysis. 

Act as the single liaison with FDA (investigator-held IND trials).

Ensure compliance with all requirements as set forth in the Code of Federal Regulations, 
applicable DF/HCC requirements, HIPAA requirements, and the approved protocol.

Commit to the provision that the protocol will not be rewritten or modified by anyone 
other than the DF/HCC Sponsor.

Identify and qualify Participating Institutions and obtain accrual commitments prior to 
extending the protocol to that site.

Monitor accrual and address Participating Institutions that are not meeting their accrual 
requirements. 
2.2    Coordinating Center 

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The general responsibilities of the Coordinating Center may include but are not limited to:

Assist in protocol development. 

Maintain FDA correspondence, as applicable.

Review registration materials for eligibility and register participants from Participating 
Institutionsin the DF/HCC clinical trial management system (CTMS)..

Distribute protocol and informed consent document updates to Participating Institutions 
as needed.

Oversee the data collection process from Participating Institutions.

Maintain documentation of Serious Adverse Event (SAE) reports and 
deviations/violation submitted by Participating Institutions and provide to the DF/HCC 
Sponsor for timely review.  

Distribute serious adverse events reported to the DF/HCC Sponsor that fall under the 
DFCI IRB Adverse Event Reporting Policy to all Participating Institutions.

Provide Participating Institutions with information regarding DF/HCC requirements that 
they will be expected to comply with.

Carry out plan to monitor Participating Institutions either by on-site or remote 
monitoring. 

Maintain Regulatory documents of all Participating Institutions which includes but is not 
limited to the following: local IRB approvals/notifications from all Participating 
Institutions, confirmation of Federalwide Assurances (FWAs) for all sites,  all SAE 
submissions, Screening Logs for all sites, IRB approved consents for all sites

Conduct regular communications with all Participating Institutions (conference calls, 
emails, etc) and maintain documentation all relevant communications.
2.3    Participating Institution
Each Participating Institution is expected to comply with all applicable federal regulations and 
DF/HCC requirements, the protocol and HIPAA requirements. 
The general responsibilities for each Participating Institution may include but are not limited to:

Document the delegation of research specific activities to study personnel.

Commit to the accrual of participants to the protocol.

Submit protocol and/or amendments to their local IRB.

Maintain regulatory files as per sponsor requirements.

Provide the Coordinating Center with regulatory documents or source documents as 
requested.

Participate in protocol training prior to enrolling participants and throughout the trial as 
required (i.e. teleconferences).

Update Coordinating Center with research staff changes on a timely basis.

Register participants through the Coordinating Center prior to beginning research related 
activities. 

Submit Serious Adverse Event (SAE) reports to local IRB per local requirements and to 
the Coordinating Center, in accordance with DF/HCC requirements. 

Submit protocol deviations and violations to local IRB per local requirements and to the 
DF/HCC Sponsor in accordance with DF/HCC requirements.

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
Order, store and dispense investigational agents and/or other protocol mandated drugs per 
federal guidelines and protocol requirements.

Have office space, office equipment, and internet access that meet HIPAA standards.

Participate in any quality assurance activities and meet with monitors or auditors at the 
conclusion of a visit to review findings.

Promptly provide follow-up and/or corrective action plans for any monitoring queries or 
audit findings.
3.    DF/HCC REQUIREMENTS FOR MULTI-CENTER PROTOCOLS
The following section will clarify DF/HCC Requirements and further detail the expectations for 
participating in a DF/HCC Multi-Center protocol. 
3.1 
Protocol Distribution
The Coordinating Center will distribute the final DFCI IRB approved protocol and any 
subsequent amended protocols to all Participating Institutions.   
3.2  
Protocol Revisions and Closures
The Participating Institutions will receive notification of protocol revisions and closures from the 
Coordinating Center.  It is the individual Participating Institution’s responsibility to notify its 
IRB of these revisions.

Non life-threatening revisions: Participating Institutions will receive written notification 
of protocol revisions regarding non life-threatening events from the Coordinating Center. 
Non-life-threatening protocol revisions must be IRB approved and implemented within 
90 days from receipt of the notification.

Revisions for life-threatening causes: Participating Institutions will receive immediate 
notification from the Coordinating Center concerning protocol revisions required to 
protect lives with follow-up by fax, mail, e-mail, etc.  Life-threatening protocol revisions 
will be implemented immediately followed by IRB request for approval.

Protocol closures and temporary holds: Participating Institutions will receive 
notification of protocol closures and temporary holds from the Coordinating Center. 
Closures and holds will be effective immediately.  In addition, the Coordinating Center, 
will update the Participating Institutions on an ongoing basis about protocol accrual data 
so that they will be aware of imminent protocol closures.
3.3   
Informed Consent Requirements
The DF/HCC approved informed consent document will serve as a template for the informed 
consent for Participating Institutions. The Participating Institution consent form must follow the 
consent template as closely as possible and should adhere to specifications outlined in the 
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Protocols.  This document will be provided separately to each Participating Institution.
Participating Institutions are to send their version of the informed consent document and HIPAA 
authorization, if a separate document, to the Coordinating Center for review and approval prior 
to submission to their local IRB. The approved consent form must also be submitted to the 
Coordinating Center after approval by the local IRB for all consent versions.
The Principal Investigator (PI) at each Participating Institution will identify the physician 
members of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. Participating institutions must follow the DF/HCC requirement that only 
attending physicians obtain informed consent and re-consent for all interventional drug, biologic, 
or device research.  
3.4  
IRB Documentation
The following must be on file with the Coordinating Center:

Initial approval letter of the Participating Institution's IRB. 

Copy of the Informed Consent Form(s) approved by the Participating Institution’s IRB. 

Participating Institution’s IRB approval for all amendments.

Annual approval letters by the Participating Institution's IRB.
3.5  
IRB Re-Approval
Verification of IRB re-approval from the Participating Institutions is required in order to 
continue research activities.  There is no grace period for continuing approvals.
The Coordinating Center will not register participants if a re-approval letter is not received from 
the Participating Institution on or before the anniversary of the previous approval date.  
3.6  
Participant Confidentiality and Authorization Statement
In 1996, congress passed the first federal law covering the privacy of health information known 
as the Health Insurance Portability and Accountability Act (HIPPA). Any information, related to 
the physical or mental health of an individual is called Protected Health Information (PHI). 
HIPAA outlines how and under what circumstances PHI can be used or disclosed. 
In order for covered entities to use or disclose protected health information during the course of a 
study, the study participant must sign an authorization statement.  This authorization statement 
may or may not be separate from the informed consent document.  The Coordinating Center, 
with the approval from the DFCI IRB will provide a consent template, with information 
regarding authorization for the disclosure of protected health information. 
The DF/HCC Sponsor will use all efforts to limit its use of protected health information in its 
trials. However, because of the nature of these trials, certain protected health information must 
be collected. DF/HCC has chosen to use authorizations, signed by the participant in the trial, 

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rather than limited data sets with data use agreements.
3.6.1  DF/HCC Multi-Center Protocol Confidentiality
All documents, investigative reports, or information relating to the participant are strictly 
confidential. Whenever reasonably feasible, any participant specific reports (i.e. Pathology 
Reports, MRI Reports, Operative Reports, etc.) submitted to the Coordinating Center should be 
de-identified. It is recommended that the assigned protocol case number (as described below) be 
used for all participant specific documents. Participant initials may be included or retained for 
cross verification of identification. 
3.7  
DF/HCC Multi-Center Protocol Registration Policy
3.7.1  Participant Registration and Randomization 
Refer to protocol Section 4.3 and 4.4 of the protocol for the participant registration 
process.
3.7.2  Initiation of Therapy
Participants must be registered with the DF/HCC CTMS before receiving treatment.  
Treatment may not be initiated until the Participating Institution receives confirmation of 
the participant’s registration from the Coordinating Center. The DF/HCC Sponsor and 
DFCI IRB must be notified of any violations to this policy.
 3.7.3 Eligibility Exceptions
No exceptions to the eligibility requirements for a protocol without DFCI IRB approval 
will be permitted. All Participating Institutions are required to fully comply with this 
requirement. The process for requesting an eligibility exception is defined below.
3.8  
DF/HCC Protocol Case Number
At the time of registration, the following identifiers are required for all subjects: initials, 
date of birth, gender, race and ethnicity. Once eligibility has been established and the 
participant successfully registered, the participant is assigned a unique protocol case 
number.  This number is unique to the participant on this trial and must be used for 
CRF/eCRF completion and correspondence.  Participating Institutions should submit all 
de-identified subsequent communication and documents to the Coordinating Center, 
using this case number to identify the subject.  
3.8.1  Protocol Deviations, Exceptions and Violations
Federal Regulations require an IRB to review proposed changes in a research activity to 
ensure that researchers do not initiate changes in approved research without IRB review 
and approval, except when necessary to eliminate apparent immediate hazards to the 

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participant. DF/HCC requires all departures from the defined procedures set forth in the 
IRB approved protocol to be reported to the DF/HCC Sponsor, who in turn is responsible 
for reporting to the DFCI IRB.
For reporting purposes, DF/HCC uses the terms “violation”, “deviation” and “exception” 
to describe departures from a protocol. All Participating Institutions must adhere to these 
requirements for reporting to the DF/HCC Sponsor and will follow their institutional 
policy for reporting to their local IRB.
3.8.2  Definitions
Protocol Deviation: Any departure from the defined procedures set forth in the IRB-
approved protocol which is prospectively approved prior to its implementation.
Protocol Exception:  Any protocol deviation that relates to the eligibility criteria, e.g.
enrollment of a participant who does not meet all inclusion/exclusion criteria.
Protocol Violation: Any protocol deviation that was not prospectively approved by the 
IRB prior to its initiation or implementation. 
3.8.3  Reporting Procedures
DF/HCC Sponsor: is responsible for ensuring that clear documentation is available in the 
medical record and/or regulatory documents to describe all protocol exceptions, 
deviations and violations. The DF/HCC Sponsor will also be responsible for ensuring that 
all protocol violations/deviations are promptly reported per DFCI IRB guidelines. 
Participating Institutions: Protocol deviations require prospective approval from the 
DFCI IRB. The Participating Institution must submit the deviation request to the 
Coordinating Center who will then submit the deviation request to the DFCI IRB. Upon 
DFCI IRB approval the deviation is submitted to the Participating Institution IRB, per 
institutional policy. A copy of the Participating Institution’s IRB report and determination 
will be forwarded to the Coordinating Center within 10 business days after the original 
submission. 
All protocol violations must be sent to the Coordinating Center in a timely manner. 
Coordinating Center:  Upon receipt of the violation/deviation report from the 
Participating Institution, the Coordinating Center will submit the report to the DF/HCC 
Sponsor for review. Subsequently, the Participating Institution’s IRB violation/deviation 
report will be submitted to the DFCI IRB for review per DFCI IRB reporting guidelines. 
3.9  
Safety Assessments and Toxicity Monitoring
The study teams at all participating institutions are responsible for protecting the safety, rights 
and well-being of study participants. Recording and reporting of adverse events that occur during 

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the course of a study help ensure the continuing safety of study participants. 
All participants receiving investigational agents and/or other protocol mandated treatment will be 
evaluated for safety. The safety parameters include all laboratory tests and hematological 
abnormalities, physical examination findings, and spontaneous reports of adverse events reported 
by participants.  All toxicities encountered during the study will be evaluated according to the 
NCI criteria specified in the protocol. Life-threatening toxicities must be reported immediately to 
the DF/HCC Sponsor via the Coordinating Center. 
Additional safety assessments and toxicity monitoring will be outlined in the protocol.
3.9.1 Guidelines for Reporting Serious Adverse Events 
Guidelines for reporting Adverse Events (AEs) and Serious Adverse Events (SAEs) are 
detailed in protocol Section 7.0.
Participating Institutions must report the SAEs to the DF/HCC Sponsor and the 
Coordinating Center following the DFCI IRB Adverse Event Reporting Policy. 
The Coordinating Center will maintain documentation of all Participating Institution 
Adverse Event reports and be responsible for communicating to all participating 
investigators, any observations reportable under the DFCI IRB Reporting Requirements.  
Participating Institutions will review and submit to their IRB according to their 
institutional policies and procedures
3.9.2 Guidelines for Processing IND Safety Reports 
The DF/HCC Sponsor will review all IND Safety Reports and ensure that all IND Safety 
Reports are distributed to the Participating Institutions. Participating Institutions will 
review and submit to their IRB according to their institutional policies and procedures.
3.10 Data Management
The DF/HCC CTRIO develops case report forms (CRF/eCRFs), for use with the 
protocol.  These forms are designed to collect data for each study. The DF/HCC CTRIO 
provides a web based training for all eCRF users.
  
3.10.1 Data Forms Review
Data submissions are monitored for timeliness and completeness of submission. If study 
forms are received with missing or questionable data, the submitting institution will receive 
a written or electronic query from the DF/HCC Office of Data Quality, Coordinating Center, 
or designee. 
Responses to all queries should be completed and submitted within 14 calendar days.  

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Responses may be returned on the written query or on an amended paper case report form, 
or in the case of electronic queries, within the electronic data capture (eDC) system. In the 
case of a written query for data submitted on a paper case report form, the query must be 
attached to the specific data being re-submitted in response.  
If study forms are not submitted on schedule, the Participating Institution will periodically 
receive a Missing Form Report from the Coordinating Center noting the missing forms. 
4.    REQUISITIONING INVESTIGATIONAL DRUG
Nivolumab will be ordered from 
 The ordering of investigational agent is specified in the 
protocol Section 8.1.8.
Carboplatin is commercially available.  Check with the local Director of Pharmacy and/or the 
Research Pharmacy to ensure that the agent is in stock. If the agent is not stocked, ensure that the 
agent can be ordered once the protocol is approved by the local IRB.
5.    MONITORING: QUALITY CONTROL
The quality control process for a clinical trial requires verification of protocol compliance and 
data accuracy. As the Coordinating Center, the DF/HCC Lead Institution with the aid of the 
ODQ provides quality control oversight for the protocol.
5.1 
Ongoing Monitoring of Protocol Compliance
The Participating Institutions will be required to submit participant source documents to the 
DF/HCC Lead Institution or designee for monitoring. Participating Institutions may also be 
subject to on-site monitoring conducted by the DF/HCC Lead Institution. 
The DF/HCC Lead Institution will implement on-site and virtual monitoring activities to ensure 
that Participating Institutions are complying with regulatory and protocol requirements, data 
quality, and subject safety. At minimum, the DF/HCC Lead Institution, or designee, will monitor 
each participating site twice a year while patients are receiving study treatment. Should a 
Participating Institution be monitored once and then not accrue any additional participants or 
participant visits, then a second monitoring visit may not be necessary. 
Monitoring practices may include but are not limited to: source verification, review and analysis 
of the following: eligibility requirements of all participants, informed consent procedures, 
adverse events and all associated documentation, study drug administration / treatment, 
regulatory records and site trial master files, protocol deviations,  pharmacy records, response 
assessments, and data management. Additionally, ongoing communication will occur through 
regularly scheduled teleconferences and by email. Source documents from Participating 
Institutions, will be collected at specific timepoints to support the primary and/or secondary 
endpoints.

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On-Site Monitoring: On-site monitoring will occur on an as-needed basis.  Participating 
Institutions will be required to provide access to participants’ complete medical record and 
source documents for verification during on-site visits. Upon request, Participating Institutions 
should provide access to regulatory documents, pharmacy records, local policies related to the 
conduct of research, and any other trial-related documentation maintained by the Participating 
site. If there are protocol compliance concerns, issues that impact subject safety or the integrity 
of the study, or trends identified based on areas of need, additional monitoring visits may occur. 
Virtual Monitoring: On-site monitoring visits will be supplemented with virtual monitoring 
visits.  The DF/HCC Lead Institution will request source documentation from Participating 
Institutions as needed to complete virtual monitoring activities. Participating Institutions will be 
asked to forward de-identified copies of participants’ medical record and source documents to 
the DF/HCC Lead Institution to aid in the source documentation verification process.
In addition to monitoring performed by the Coordinating Center, the DF/HCC ODQ may 
monitor data for timeliness of submission, completeness, and adherence to protocol 
requirements. The DF/HCC Lead Institution or designee and, if applicable, the ODQ Data 
Analysts will perform ongoing protocol data compliance monitoring with the support of the 
Participating Institution’s Coordinators, the Principal Investigators, and the Protocol Chair. 
5.2 
Monitoring Reports
The DF/HCC Sponsor will review all monitoring reports for on-site and remote monitoring of 
Participating Institutions to ensure protocol compliance. The DF/HCC Sponsor may increase the 
monitoring activities at Participating Institutions that are unable to comply with the protocol, 
DF/HCC Sponsor requirements or federal and local regulations. Participating Institutions may 
also be subject to an audit as determined by the DF/HCC Sponsor.
5.3 
Accrual Monitoring
Prior to extending a protocol to an external site, the DF/HCC Sponsor will establish accrual 
requirements for each participating institution. Accrual will be monitored for each participating 
institution by the DF/HCC Sponsor or designee. Sites that are not meeting accrual expectations 
may be subject to termination.  Sites are expected to accrue at least 3 patients per year.
6.    AUDITING: QUALITY ASSURANCE
Auditing is a method of Quality Assurance. Its main focus is to measure whether standards and 
procedures were followed. Auditing is the systematic and independent examination of all trial 
related activities and documents.  Audits determine if evaluated activities were appropriately 
conducted and whether data was generated, recorded and analyzed, and accurately reported per 
the protocol, Standard Operating Procedures (SOPs), and the Code of Federal Regulations 
(CFR).
6.1 
Audit Plan: DF/HCC Sponsored Trials

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All Participating Institutions are subject to audit by the DF/HCC Office of Data Quality (ODQ). 
Typically, approximately 3-4 participants would be audited at the site over a 2 day period. If 
violations which impact participant safety or the integrity of the study are found, more 
participant records may be audited. 
6.2 
Audit Notification
It is the Participating Institution’s responsibility to notify the Coordinating Center of all 
scheduled audit dates (internal or external) and re-audit dates (if applicable), which involve this 
protocol. All institutions will forward a copy of final audit and/or re-audit reports and corrective 
action plans (if applicable) to the Coordinating Center, within 12 weeks after the audit date. 
6.3 
Audit Reports 
The DF/HCC Sponsor will review all final audit reports and corrective action plans if applicable. 
The Coordinating Center, must forward these reports to the DF/HCC ODQ per DF/HCC policy 
for review by the DF/HCC Audit Committee. Based upon the audit assessments the DF/HCC 
Audit Committee could accept or conditionally accept the audit rating and final report. 
Conditional approval could require the DF/HCC Sponsor to implement recommendations or 
require further follow-up.  For unacceptable audits, the DF/HCC Audit Committee would 
forward the final audit report and corrective action plan to the DFCI IRB as applicable.
6.4 
Participating Institution Performance
The DF/HCC Sponsor and the DFCI IRB are charged with considering the totality of an 
institution’s performance in considering institutional participation in the protocol.
6.4.1 Corrective Actions
Participating Institutions that fail to meet the performance goals of accrual, submission of 
timely and accurate data, adherence to protocol requirements, and compliance with state 
and federal regulations, may be recommended for a six-month probation period. Such 
institutions must respond with a corrective action plan and must demonstrate during the 
probation period that deficiencies have been corrected, as evidenced by the improved 
performance measures. Participating Institutions that fail to demonstrate significant 
improvement will be considered by the DF/HCC Sponsor for revocation of participation. 
A DF/HCC Sponsor and/or the DFCI IRB may terminate a site’s participation if it is 
determined that a site is not fulfilling its responsibilities as described above.

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 Protocol Version Date:02/02/21
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APPENDIX C
DIET AND PHYSICAL ACTIVITY ASSESSMENTS
Please note: the below is a copy of the Block Fat/Sugar/Fruit/Vegetable Screener for 
reference. Please use the official Scantron version of the Screener rather than the appendix. 

DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
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DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
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DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
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DF/HCC Protocol #:17-512
 Protocol Version Date:02/02/21
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APPENDIX D
DIET AND PHYSICAL ACTIVITY ASSESSMENTS
Below is a copy of the Gordin Leisure-Time Exercise Questionnaire (LSI) with three 
additional questions about fiber intake from the Block Vegetable/Fruit/Fiber Screener.